Carnarvon Private Hospital Trust

Carnarvon Private Hospital Trust

Introduction

This report records the results of aSurveillance 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 byThe 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:Carnarvon Private Hospital Trust

Premises audited:Carnarvon Private Hospital

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

Dates of audit:Start date: 6 May 2016End date: 6 May 2016

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:33

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

Carnarvon Private Hospital Ltd provides residential care for up to 40 residents. Occupancy on the day of the audit was 33. The private hospital is owned by The Carnarvon Hospital Trust Board which has three directors. A facility manager is onsite five days per week. This unannounced surveillance audit was undertaken to verify on-going compliance with specified parts of the Health and Disability Services Standard and the district health board aged care contract.

There were two previous required improvements identified at the last audit which have been effectively closed. Two new areas for improvement were identified. These included medication management and nutrition, safe food and fluid 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.

Communication processes were appropriate to the residents’ needs. Open disclosure procedures ensured that communication was maintained in an open and transparent manner. Communication with residents and family about adverse events and other matters were documented. Residents and families interviewed confirmed good communication between management, staff, families and residents.

The complaints process complied with Right 10 of the Code. A complaints register was maintained. There were no complaints outstanding at the time of the audit. Complaints were used to improve the quality of service delivery.

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.

Systems were developed and implemented, which defined the scope, direction and goals of the organisation. Monitoring and reporting processes were in place. Quality goals and activities were defined and reviewed.

The facility manager was responsible for the overall service delivery, quality systems and human resource management. The facility manager was supported by a clinical charge nurse, a director and administrative staff.

The required policies and procedures were documented and controlled. An audit schedule was implemented and an incident and adverse event reporting system was planned and coordinated. Registered nurses were employed to cover twenty four hours a day.

A previous improvement to the quality system had been addressed.

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.

The residents and family/whānau report satisfaction with the care and services provided. Services are provided by suitably qualified and skilled staff to meet the needs of the residents. Electronic interRAI assessment processes, care planning, review and evaluation are undertaken within timeframes to meet standard and agreement requirements. Long term care plans clearly identify residents’ current needs. They are updated to show any changes in care that may be required. Medical reviews undertaken by the general practitioner (GP) meet required timeframes.

Pressure injury management and responsibilities are documented in policy and implemented. The service has documentation to show that all reporting requirements are met.

There are planned activities suitable for all residents’ acuity levels. Planning shows that each resident’s strength and interest is incorporated into activities offered. The residents are encouraged to access and/or participate in local community facilities. Having fully attained the criterion the service can in addition clearly demonstrate that resident numbers attending at least one daily activity has risen since the previous audit and they have gained a higher than usual attainment level. The residents report very high satisfaction with the range and variety of activities provided.

Policy and procedures describe the safe management of medications. Safe medication administration practices were observed during the medication round. The staff responsible for medication management undertake annual competencies to ensure they can perform the role safely. An area identified for improvement relates to how medications are documented.

Food and fluids are provided to meet the needs of residents living in a long term care environment as identified by the dietitian approved menu. An area identified for improvement in the previous audit related to food and nutrition is now fully attained. However, a new area has been identified for improvement related to meat in the freezer not being labelled.

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 had a current building warrant of fitness and this was displayed. The fire evacuation plan was approved and trial evacuations were conducted as required.

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 processes for determining safe and appropriate restraint and enabler use. On the day of the audit the restraint register is up to date for all residents who required interventions for safety. The methods used for assessment, consent and approval, monitoring, evaluation and review meet the requirements of the Restraint Minimisation and Safe Practice Standards. One previous area of improvement has been addressed.

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 management system in place is appropriate for the size and type of services offered. The risk of infection is reduced for residents, staff, families/whānau and visitors.

The infection control coordinator collates the monthly surveillance data and this is reviewed, analysed and sent to a contracted infection control management service for analysis. Any upward trending is managed via a corrective action process. The infection surveillance data results are shared at management and staff levels.

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 / 1 / 14 / 0 / 1 / 1 / 0 / 0
Criteria / 1 / 39 / 0 / 1 / 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 1.1.13: Complaints Management
The right of the consumer to make a complaint is understood, respected, and upheld. / FA / The facility manager is responsible for managing complaints and there is a system in place to manage the complaints process. A complaints register is maintained that includes some minor complaints that had been managed appropriately and closed off effectively.
The Complaints/Advocacy Management policy reviewed is compliant with Right 10 of the Code. Systems are in place to ensure residents and their families are advised on entry to the facility, of the complaints process and the Code. Resident and family demonstrated an understanding and awareness of these. Review of the staff meeting minutes provided evidence of reporting of complaints to staff. Staff confirmed these discussions occurred at staff meetings and saw complaints as a service quality improvement.
Standard 1.1.9: Communication
Service providers communicate effectively with consumers and provide an environment conducive to effective communication. / FA / The open disclosure policy is clearly documented to include communication principles. Resident and family have a right to know what has happened to them and to be fully informed. There is family/whanau communication evident in the progress notes in the residents` records reviewed.
The cultural appropriate policy documents that residents and families who do not speak English shall be advised of the availability of an interpreter or an advocate at the first point of contact with the service. The interpreting and translation service is a twenty four hour service.
The facility manager spoke highly of the staff and the excellent communication and relationship between them and the GP who was unable to be interviewed and the communication with the contracted pharmacist.
Families interviewed confirmed they are kept well informed of the resident`s status, including any adverse events affecting the resident. Evidence of open disclosure is documented in the residents’ records reviewed, the incident forms and the complaints process.
The service promotes an environment that optimises communication and staff education related to appropriate communication methods.
Standard 1.2.1: Governance
The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers. / FA / The service has a philosophy of care and objectives of service delivery are clearly documented. The strategic plan 2012 – 2017 was reviewed last in October 2015. There are eight main objectives and most of these have already been achieved. New initiatives have been introduced to meet the needs of residents and numerous quality improvements to the facility and availability of resources is maintained.
Quality improvements have included a new call bell system and installation of Wifi, replacement of all beds and bedside lockers increased educational opportunities for staff and minimal staff turnover. Registered nurses are encouraged to complete the interRAI training. Two registered nurses are enrolled for 2016 to complete the appropriate training, and two registered nurses are booked to complete the refresher training this year.
The facility manager has been at this facility for forty two years. There is a stable core of staff and staff education has always been a priority. The service has maintained and has recently been awarded tertiary status for workplace health and safety. The facility manager has just resigned from her position of facility manager. The facility manager reports to the Carnarvon Hospital Trust Board on a monthly basis and minutes of meetings held are available and were reviewed.
The facility manager has completed and attended education relevant to the position and to maintain the requirement for the New Zealand Nurses Council annual practising certificate and a record is maintained. The new management role is a temporary position and the new manager will be commencing in two weeks. An orientation period provided by the facility manager is planned in advance and was discussed.
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 and risk management plan was reviewed and is used to guide the quality programme. Currently the responsibility of risk management is delegated to the facility manager from the Trust. Risk includes corporate governance risk, patient centred care, clinical staff related risk, staff employment related risk, environmental risk and financial risk.
Policies and procedures are relevant to the scope and complexity of the service and reflect current accepted good practice. All documents are controlled and there is a process underway to improve this process. All staff have been made aware of the policy updates. There is evidence in the staff meeting minutes that staff have been updated. Staff interviewed stated that policies are part of the orientation programme for new staff.
An annual audit schedule is documented and implemented. Audits are conducted by the appropriate staff member such as a registered nurse, infection prevention co-ordinator, dietitian, facility manager and/or quality assurance or charge nurse.
Staff meetings are held on a regular basis and a set agenda is presented that includes the required quality data and includes health and safety and infection control is discussed.
A health and safety manual is available. The service has maintained tertiary ACC workplace safety since 2007. There is a hazard reporting system as well as a hazard register, that identifies health and safety risk.