Orewa Beachview Retirement Home Limited - Orewa Secure Care

Orewa Beachview Retirement Home Limited - Orewa Secure Care

Introduction

This report records the results of a Certification 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: Orewa Beachview Retirement Home Limited

Premises audited: Orewa Secure Care

Services audited: Hospital services - Geriatric services (excl. psychogeriatric); Dementia care

Dates of audit: Start date: 24 November 2015 End date: 25 November 2015

Proposed changes to current services (if any): The service plans to convert one single occupancy room in the rest home/hospital section to double occupancy room. This will increase capacity to 30 residents (15 in the rest home hospital and 15 in the dementia unit).

Total beds occupied across all premises included in the audit on the first day of the audit: 27

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

Orewa Beachview Retirement Home (trading as Orewa Secure Care) can provide rest home, hospital and secure dementia care services for up to 29 residents. At the time of audit there were residents receiving hospital and secure dementia rest home level of care. At the time of audit, all rooms were single occupancy, with the service wanting to convert one of the single rooms in the rest home/hospital wing to a double occupancy room, which will increase the capacity of the service to 30 residents.

This certification audit was conducted against the Health and Disability Services Standards and the service’s contract with the district health board. The audit process included the review of documentation, observations and interviews. The audit report is an evaluation of the combined evidence on how the service meets each of the standards.

There are three areas requiring improvement identified at this audit. These relate to ensuring appropriate call and privacy systems are implemented prior to use of the current single room as a double room, recording the staff member’s name in progress notes and the detail in the evaluation of care.

Positive feedback was received from the families and residents regarding the quality of the care provided under the new management.

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.

Staff demonstrated good practice related to respecting residents’ rights in their day to day interactions and this was confirmed during interviews with residents and family/whānau members. Staff receive ongoing education on the Health and Disability Commissioner's (HDC) Code of Health and Disability Services Consumers' Rights (the Code). The staff interviewed were able to verbalise their knowledge and understanding of residents’ rights.

Policies and procedures describe how residents from a range of cultures, including Māori, have their individual cultural values and beliefs identified and respected by the service. Currently there are no residents who identify as Māori. The service provider reports there are no known barriers to Māori residents accessing the service.

Written consent to receive services is obtained from the residents or their appointed guardians or enduring power of attorney (EPOA). Information on informed consent is provided in the residents' admission pack and is fully explained as part of the admission process to reflect policy requirements.

Orewa Secure Care provides services that reflect current accepted good practice. Evidence-based practice was observed, promoting and encouraging good practice.

Resident and family/whānau members confirmed during interview that visitors are welcomed and that communication is open and honest and that they are kept informed if staff have any concerns or if there is a change in their relative’s condition.

The complaints process is documented and all complaints, including external complaints, were effectively closed out.

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.

Organisational structures and processes are monitored at organisational level. Service performance is aligned with the organisation`s philosophy and goals identified in the quality and risk plan.

The service has a documented quality and risk management system that supports the provision of clinical care and support. Policies are reviewed by the management team annually and quality and risk performance is reported through meetings at the facility and monitored by the management team. Review of service delivery includes incidents/accidents, infections, complaints and reports from the internal audit programme.

The adverse event reporting system is planned and coordinated with staff documenting and reporting adverse, unplanned or untoward events.

Policies and procedures are documented to guide staff on all aspects of service delivery. The manager is suitably qualified and is supported by a clinical manager. Resident and staff records reviewed were well documented and maintained by the clinical nurse manager and the manager. There has been a change in the management team in the past two months.

Systems for human resources management are established and implemented. The education programme for all staff is available and planned for the year. The required training for staff who work in the dementia unit is provided.

Resident information is uniquely identifiable, accurately recorded, kept up to date and privacy is protected. Stored records are secure. Staff do not use their full name when signing what they have written in residents’ progress notes. This is an area identified for improvement.

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 low risk.

Entry criteria for the services are communicated to family/whānau or the resident’s nominated EPOA and referring agencies. Management confirmed that if entry to the service was to be declined, a record would be maintained and the potential resident’s family/whānau would be referred to a more appropriate service.

Residents receive timely, competent, and appropriate services in order to meet their assessed need. The processes for assessment, planning, provision, evaluation, review and exit are provided within required time frames to meet contractual requirements using both interRAI and paper based assessments. The service is coordinated in a manner that promotes continuity in service delivery and a team approach to care delivery.

The care plans reviewed described the required support and interventions consistent with residents’ assessed needs. Care plans are evaluated at least six monthly, or sooner if there is a change in the resident’s needs. Not all evaluations identify if the resident’s goals are being met and this requires improvement. Where progress is different from expected, the service responds by initiating changes to the care plan or with the use of short term care plans.

Support for residents to access or be referred to other health and/or disability service providers is appropriately facilitated to meet their needs. The processes in place related to transition, discharge or transfer identify known risks to ensure this is managed safely.

An activities programme is managed and implemented by providing a variety of group and individual activities to meet the interests of residents.

Medicine systems implemented reflect safe medicine management processes. Staff responsible undertake annual assessments to show they are competent to perform the role safely.

The menu has been reviewed by a registered dietitian as suitable for the older person living in long term care. Snacks are available 24 hours a day. There were no negative comments made during interviews related to food.

Residents and family/whānau confirmed the delivery of services meets their needs and wants.

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. / Some standards applicable to this service partially attained and of low risk.

All building and plant complies with legislation with a current building warrant of fitness displayed. Ongoing maintenance ensures the building is maintained to a high standard. Fixtures, fittings, floor and wall surfaces are suitable for this environment. All rooms have access to ensuite toilet and hand basin facilities. There are adequate toilets, showers, and bathing facilities located throughout the facility that provides privacy.

The environment is appropriate for rest home/hospital and specialist dementia level of care services. All areas ensure physical privacy is maintained and have adequate space and amenities to facilitate independence. There are processes in place to protect residents, visitors, and staff from exposure to waste and infectious or hazardous substances.

The laundry service for the linen is provided by an external contractor and conducted offsite. There is some resident’s personal laundry done onsite. There are processes in place to provide safe and hygienic cleaning services.

The facility had an appropriate call system installed. There is access to external gardens and verandas off most rooms. The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the residents. The secure dementia unit is separated from the rest home/hospital section.

Routine safety checks and internal audits are performed by maintenance personnel and management. Emergency preparedness was evident with adequate resources being available in the event of an emergency. Staff are trained appropriately in all aspects of health and safety in the work place.

There will be some changes required to the room that is proposed to be a shared room, before this room can be used for two residents.

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.

The service has a commitment to minimising and appropriate use of restraints and enablers. Restraint and enablers are only used as a last resort to maintain the resident’s safety and comfort. Clear definitions in the policies reviewed ensured staff understood the implication of restraint and enabler use. There were seven residents using restraint (bed rail or lap belt) and one resident with an enabler (bed rail) in use.

There are appropriate processes in place to ensure that when restraints and enablers are used a sound assessment, review and evaluation process is occurring. The restraint minimisation committee monitors and approves all restraint use. As part of the internal auditing programme the service conducts six monthly quality reviews of their use of restraint.

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 is implemented by the service. This process is overseen by the infection prevention and control coordinator. Policies and procedures describe all aspects of infection control good practice which are suitable for the level of care provided at the service. There are adequate resources to allow for a managed environment which minimises the risk of infection to residents, staff and visitors. The infection control programme is reviewed annually.

Surveillance for infections is conducted monthly with agreed objectives, priorities, and methods that have been specified in the infection control programme. Results of surveillance, conclusions, and specific recommendations to assist in achieving infection reduction and prevention outcomes are acted upon, evaluated and reported to staff and management in a timely manner. Data is trended monthly on-site and benchmarked quarterly by an off-site provider to show any variance in infection rates. Follow up corrective actions would be undertaken as required. Documentation identifies that the service managed an influenza outbreak using good practice standards, including reporting requirements.