Lyndale Care Limited - Lyndale Villa and Manor

Lyndale Care Limited - Lyndale Villa and Manor

Introduction

This report records the results of a Provisional 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:Lyndale Care Limited

Premises audited:Lyndale Villa||Lyndale Manor

Services audited:Rest home care (excluding dementia care); Dementia care

Dates of audit:Start date: 8 October 2015End date: 9 October 2015

Proposed changes to current services (if any):Proposed change of ownership from Lyndale Rest Home Limited to Lyndale Care Limited.

Total beds occupied across all premises included in the audit on the first day of the audit:47

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.

General overview of the audit

Lyndale Villa and Lyndale Manor provide rest home level care, including independent living units and rest home dementia level care and for up to 56 residents. The facilities are currently operated by Lyndale Rest Home Limited. The services are managed by a general manager.

This provisional audit was undertaken to establish the extent to which the existing provider conforms 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 is to provide a health and disability service. The prospective provider, the director for Lyndale Care Limited was interviewed during this audit.

The audit process included the review of policies and procedures, review of residents’ and staff files, observations and interviews with residents, families, management, staff and a general practitioner.

Residents and family members interviewed provided positive feedback on the care provided.

There are eight areas identified during this audit that require improvement relating to: staff documentation; ongoing education; resident documentation; planned activities; referral of residents for reassessment at Lyndale Manor; and repairs and maintenance at both sites.

Consumer rights

Systems and processes are in place to ensure that the independence, personal privacy and dignity of residents are respected, and that residents are kept safe. There is regular and ongoing training on residents’ rights, and staff demonstrated a good understanding of how these could be implemented in their daily practice. During the audit visit, residents were observed to be treated in a professional and respectful manner.

Services provided to residents are of an appropriate standard. There was evidence of open and ongoing communication with residents and families.

The general manager is responsible for the management of complaints and a complaints register is maintained.

Organisational management

Lyndale Rest Home Limited is the governing body and is responsible for the services provided. A business strategic plan and quality and risk management systems are fully implemented at Lyndale Villa and Lyndale Manor and documented scope, direction, goals, values, and mission statement were reviewed. Systems are in place for monitoring the services provided including regular monthly reporting by the general manager to the governing body.

The prospective provider advised Lyndale Care Limited will be the governing body. The new owner and director for Lyndale Care Limited advised they are proposing to purchase the facility and assume responsibility for the provision of services from late November 2015. The prospective provider owns and manages another aged care facility in the region. A business plan, a transition plan with timeframes, a quality and risk management plan and an organisational structure for the prospective provider was reviewed.

The facility is managed by an experienced general manager who is non-clinical and has been working in this role for many years. The general manager is supported by a clinical leader who is a registered nurse and a quality assurance coordinator. The clinical leader is responsible for oversight of the clinical service in the two facilities.

Quality and risk management systems are in place. There is an internal audit programme, risks are identified and there is a hazard register. Adverse events are documented on accident/incident forms. Internal audits, accident/incident forms, and meeting minutes evidenced corrective action plans are being developed, implemented, monitored and signed off as being completed to address the issue/s that required improvement. Staff meetings are held and there was reporting on numbers of various clinical indicators, quality and risk issues and discussion of any trends identified in these meetings. Graphs of clinical indicators were available for staff to view along with meeting minutes.

There are policies and procedures on human resources management, however not all required documentation was sighted on staff files. Staff are required to complete the New Zealand Qualifications Authority Unit Standards. An in-service education programme is provided for staff. Staff files evidenced low attendance at training sessions and there was no evidence of restraint competencies for clinical staff.

There is a documented rationale for determining staffing levels and skill mixes in order to provide safe service delivery that is based on best practice. The general manager and registered nurses are rostered on call after hours.

Resident information is entered into a register in an accurate and timely manner. The privacy of resident information is maintained. The name and designation of staff making entries into residents’ clinical records was legible.

Continuum of service delivery

Registered nurses are on duty each weekday, for three hours each weekend day, and are available on call at all other times to guide care delivery staff. Continuity of care is promoted by the updating of residents’ progress notes every shift, verbal handovers and facility diaries. Care plans are individualised based on a range of clinical information and include input from residents and families. The evaluation of nursing care plans within required timeframes, the referral of residents for reassessment of the level of care needed when their condition changes, and residents requiring specialist dementia care having detailed care plans related to minimising episodes of challenging behaviour, are all areas for improvement.

The kitchens in both facilities are maintained in a clean and hygienic manner and all aspects of food service delivery are well managed. The individual food preferences and dietary needs of residents are respected and catered for and residents/families reported their satisfaction with the food services.

Medications are prescribed in accordance with legislative requirements and safe practice requirements. Medications are administered by registered nurses and senior caregivers who have been assessed as competent in relation to medicines management. The management of medications is safe and appropriate, with the exception of ensuring that medications are discarded when past their ‘best-before’ date, which requires improvement.

Three activities staff manage the activities programme offered across the service, which includes a variety of individual and group activities. Residents are encouraged to maintain their links with the community and a facility van is available to take residents on outings or attend activities in the community. For residents requiring specialist dementia care, the development of individual 24-hour activities plans for each resident, and ensuring an ongoing activities programme when activities staff are not on site, are areas for improvement.

Safe and appropriate environment

A current building warrant of fitness is displayed at both sites. A preventative and reactive maintenance programme includes equipment and electrical checks. As a result of water damage, repairs and maintenance is required at both Lyndale Villa and Lyndale Manor.

All residents’ bedrooms provide single accommodation and most have full ensuites. Residents' rooms have adequate personal space provided. A number of lounges, dining areas and alcoves are available. External areas are safe and there are shaded areas available and seating is provided.

Appropriate call bell systems are available and security and emergency systems are in place.

Protective equipment and clothing is provided and used by staff. Chemicals, soiled linen and equipment were safely stored. All laundry is washed on site and cleaning and laundry systems, including appropriate monitoring systems, are in place to evaluate the effectiveness of these services.

Restraint minimisation and safe practice

There are documented guidelines on the use of restraints and enablers and behaviours of concern. Currently there are no residents using restraint or enablers. In the event of restraint use, the required approval, consent, assessment, monitoring and review would be completed.

Infection prevention and control

Infection prevention and control systems are in place, with staff offered regular education related to infection control. Personal protective equipment is freely available to staff, and additional supplies are on site should there be an infection outbreak. The infection control programme is reviewed annually. The infection control coordinator is a registered nurse. Infection surveillance is undertaken on an ongoing process, and reported monthly to senior management and staff.

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 / 39 / 0 / 3 / 3 / 0 / 0
Criteria / 0 / 85 / 0 / 4 / 4 / 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 orientation programme for new staff includes education related to the Health and Disability Commissioner’s Code of Health and Disability Services Consumer’s Rights (the Code), as confirmed in staff interviews and orientation checklists. Education on the Code is also made available to staff annually, as confirmed in the education plan and training records. Education on the Code was last undertaken in September 2015. Refer also to Criterion 1.2.7.5.
On interview staff demonstrated a clear understanding of the Code and were able to explain how this was incorporated into their everyday practice.
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 / Well-documented policies guide service providers in relation to informed consent. Completed consent forms were seen in all residents’ records reviewed. Each resident, and/or their enduring power of attorney (EPOA), completes a comprehensive consent form at the time of admission. Consent is reviewed on an as-required basis, such as when a resident’s needs change, or additional medical/surgical treatment is required. Residents and staff interviewed confirmed they were consistently given the opportunity to make informed choices and that their consent was obtained and respected.
The sighted admission agreement, which is completed by each new resident and/or their family member, contains service inclusions and exclusions. A database is maintained to ensure that signed admission agreements are held for every resident.
The clinical leader advised that only one resident currently has an advance directive, and this has been incorporated into their plan of care. All residents’ records reviewed contained a completed resuscitation status form, which included information about resident and family input into the decision, and had been authorised by the doctor. It is recommended that a process is established to review these forms regularly.
Standard 1.1.11: Advocacy And Support
Service providers recognise and facilitate the right of consumers to advocacy/support persons of their choice. / FA / Residents and family members confirmed on interview their awareness of the Advocacy Service and how to access this. As part of the admission process all residents are given a copy of the Code, which includes information on the Advocacy Service. Copies of the Advocacy Service brochure were also available at reception.
Staff training records confirmed that information on the Advocacy Service is included in the staff orientation programme and in the ongoing education programme for staff. Refer also to Criterion 1.2.7.5. Staff demonstrated familiarity with the services offered by the Advocacy Service.
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 / The service has unrestricted visiting hours and visitors are encouraged. All family members interviewed stated that they visited regularly, and always felt welcome.
If residents are well enough, they are encouraged to maintain their community interests, and to visit families. Processes are in place to facilitate rest home residents having overnight stays with families where appropriate.
Outings are organised using the service’s van that enable residents to participate in community events, while community groups and entertainers visit the facility regularly.
Residents are also supported to access health care services outside of the facility, such as visits to the dentist or to specialist medical services.
Standard 1.1.13: Complaints Management
The right of the consumer to make a complaint is understood, respected, and upheld. / FA / The general manager is responsible for complaints and there are appropriate systems in place to manage the complaints processes. A complaints register is maintained that included four complaints for 2015 and these were managed appropriately.
Complaints policies and procedures are compliant with Right 10 of the Code. Systems are in place to ensure residents and their family are advised on entry to the facility of the complaint processes and the Code. Residents and families demonstrated an understanding and awareness of these processes.
The complaints process was readily accessible and/or displayed. Review of staff meeting minutes provided evidence of reporting of any complaints to staff. Care staff confirmed this information is reported to them via the staff meetings.
The general manager advised there have been no investigations by the Ministry of Health, Health and Disability Commissioner, DHB, Accident Compensation Corporation (ACC) Coroner or Police since the previous audit.
Standard 1.1.2: Consumer Rights During Service Delivery
Consumers are informed of their rights. / FA / The prospective provider demonstrated knowledge and understanding of consumer rights.
As part of the admission process, each new resident/family is provided with a copy of the Code which also includes information on the Nationwide Health and Disability Advocacy Service (Advocacy Service). This information is discussed with them by management or senior clinical staff who answer any questions that may arise. Further discussions and explanations are provided as required by the individual resident and/or their family. Copies of the Code, and the information on the Advocacy Service, were easily accessible at both facilities. The results of the 2014 satisfaction survey indicated that residents/families were very satisfied that residents’ rights were being respected.