Eastern Services Limited - Gulf Views Rest Home

Eastern Services Limited - Gulf Views Rest Home

Introduction

This report records the results of aCertification 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:Eastern Services Limited

Premises audited:Gulf Views Rest Home

Services audited:Rest home care (excluding dementia care)

Dates of audit:Start date: 18 January 2016End date: 19 January 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:43

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

Gulf Views Rest Home, is a family owned, purpose built aged care facility that provides rest home level of care for up to 45 residents. At the time of audit there were 43 residents at the service. The strengths of the service include strong connections to the local community and the residents’ satisfaction with the care and services provided.

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 onsite documentation review included a selected number of residents’ files. Interviews were conducted with the management team, clinical and non-clinical staff, residents, family/whanau and a general practitioner to verify the documented evidence. This audit report is an evaluation of the combined evidence on how the service meets each of the standards.

The service demonstrates compliance with all the relevant standards for an aged care facility.

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 knowledge and practice of respecting residents’ rights in their day to day interactions. Staff receive ongoing education on the Health and Disability Commissioner's (HDC) Code of Health and Disability Services Consumers' Rights (the Code). Families interviewed reported that staff work in a caring manner and respect each resident.

There are no residents who identify as Maori residing at the service at the time of audit.

Written consents are obtained from the residents' family/whanau, enduring power of attorney (EPOA) or appointed guardians. Signed consent forms were sighted in all residents' files reviewed.

The organisation provides services that reflect current accepted good practice and this was sighted in the progress notes.

There is a fair and easily accessible complaints management system. Complaints and compliments are recorded. There are no outstanding complaints.

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.

The service’s philosophy and vision is to uphold the dignity, individuality, privacy and freedom of choice for all residents. This philosophy is evidenced in the organisation’s documents and management structure, to provide services that meet the needs of the residents and the community. There is a close linkage to local community volunteer groups, aged care services and religious groups.

The service is run by a suitably qualified and experienced nurse manager. The nurse manager is responsible for the overall running and resourcing of the clinical aspects of service delivery, with the owners and management team being responsible for the financial management of the service.

The service has a documented quality and risk management system that supports the provision of clinical care and support. Policies are reviewed by the nurse manager and senior staff team on a two yearly basis or when there is a change in legislation. The quality and risk performance is reported through meetings at the facility and monitored by the management team at the management meetings.

The adverse event reporting system is planned and coordinated with staff documenting and reporting adverse, unplanned or untoward events. The adverse events are reviewed and actions implemented to make improvement to care and service delivery.

Systems for human resources management are established and implemented. There are staff numbers and skill mix meet the requirements of rest home level of care. The education programme for all staff is available and planned for the year.

There is no information of a personal and private nature on public display. Current residents’ records and past residents’ archived records are securely stored.

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.

Pre-admission information clearly and accurately identifies the services offered. The service has policies and processes related to entry into the service.

Residents have an initial nursing assessment and care plan developed by the registered nurse (RN) on admission to the service. The service meets the contractual time frames for the development of the long term care plan. When there are changes in the resident’s needs, a short term care plan is implemented to reflect these changes. The care plan evaluations are conducted at least six monthly on all aspects of the care plan.

All new residents have InteRAI assessments completed and existing residents’ assessments are updated using the InteRAI process on review dates.

Residents are reviewed by a GP on admission to the service and at least three monthly, or more frequently to respond to any changing needs. The provision of services is provided to meet the individual needs of the residents. A team approach to care is provided ensuring continuity of services. Referrals to other health and disability services is planned and coordinated, based on the individual needs of the resident. The families interviewed reported that care plans are implemented and that the service manages the residents in a professional manner.

The service has a planned activities programme to meet the recreational needs of the residents. Residents are encouraged to maintain links with their family and the community.

A safe medicine administration system was observed at the time of audit. The service has documented evidence that staff responsible for medicine management are assessed as competent to do so.

Residents' nutritional requirements are met by the service with likes, dislikes and special diets catered for and food available 24 hours a day. The service has a four week, summer/winter rotating menu which is approved by a registered dietitian.

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.

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 made of acceptable materials for this environment. All rooms have access to either single or shared ensuites or centrally located bathing and toileting facilities. There are adequate toilets, showers, and bathing facilities located throughout the facility that provide adequate privacy.

The environment is appropriate for the rest home level of care offered. All areas ensure physical privacy is maintained and have adequate space and amenities to facilitate independence.

Emergency preparedness was evident with adequate resources being available in the event of an emergency. All staff are trained appropriately in all aspects of health and safety in the work place.

Most of the laundry is conducted onsite, with some of the linen being laundered by an offsite contractor. There are processes in place to provide safe and hygienic cleaning services.

Processes reviewed protect residents, visitors, and staff from exposure to waste and infectious or hazardous substances.

The facility has an appropriate call bell system installed. There is access to external gardens and verandas off all rooms. The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the residents.

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. All staff are trained appropriately in all aspects of health and safety in the work place.

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.

There are no residents requiring the use of restraint. Enablers are only used as a last resort to maintain the resident’s safety and comfort. Clear definitions in the policies reviewed ensure staff understand the implications of restraint and enabler use.

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 aims to prevent the spread of infection and reduce the risks to residents, staff and visitors. The surveillance programme is appropriate for the size and nature of the services provided. Monthly surveillance data and audits are recorded, collated and reported to management, and quarterly data to the contracted infection control advisory service.

The Infection Control Coordinator (ICC) is suitably qualified for the role and implements and reviews the infection control programme annually.

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 / 45 / 0 / 0 / 0 / 0 / 0
Criteria / 0 / 93 / 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 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 1.1.1: Consumer Rights During Service Delivery
Consumers receive services in accordance with consumer rights legislation. / FA / Staff interviewed demonstrated their knowledge of the Code of Health and Disability Services Consumers' Rights (the Code). The Code is included in staff orientation and in the annual in-service education programme, which was sighted. Residents' rights are upheld by staff (eg, staff knocking on residents' doors prior to entering their rooms, staff speaking to residents with respect and dignity, staff calling residents by their preferred names). Staff observed on the days of the audit demonstrated knowledge of the Code when interacting with residents.
The residents and relatives interviewed reported that they are treated with respect and dignity.
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 / Evidence was seen of the consent process for the collection and storage of health information, outings and indemnity, use of photographs for identification, sharing of information with an identified next of kin, and for general care and treatment. The resident’s right to withdraw consent and change their mind is noted on the form. Information is provided on enduring power of attorney (EPOA) and ensuring where applicable this is activated.
There are guidelines in the policy for advance directives which meet legislative requirements. The consent can be reviewed and altered as the resident wishes. The NM discusses information on informed consent with the resident and family on admission. An advance directive enables a resident to choose if they would like active medical treatment to prolong life, transfer to the base hospital for on-going treatment or receive ‘comfort care’. The files reviewed have signed advance directive forms which meet legislative requirements
Family members and residents are actively involved and included in care decisions as evidenced in residents' files reviewed.
Standard 1.1.11: Advocacy And Support
Service providers recognise and facilitate the right of consumers to advocacy/support persons of their choice. / FA / Advocacy information is available in brochure format at the entrance to the facility. Residents and their families were aware of their right to have support persons as confirmed in interviews.
Education from the Nationwide Health and Disability Advocacy Service is undertaken annually as part of the in-service education programme. The staff interviewed reported knowledge of residents’ rights and 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 / Residents reported on interview that they are supported to be able to remain in contact with the community by outings and the walks to local shops and parks. Policy includes procedures to be undertaken to assist residents to access community services and a van is available.
There is portable phone which is taken to the residents as required.
Evidence in files reviewed showed attendance at the DHB for appointments as required.
Standard 1.1.13: Complaints Management
The right of the consumer to make a complaint is understood, respected, and upheld. / FA / The complaints process sighted identified the required procedures. Complaints have been dealt with in a professional manner with consideration to any cultural or other values. Complaints are actively managed in a timely manner and in accordance with the complaints policy, and any other statutory requirements relevant to the specific situation.
Complaints management information is included in resident information packs given on admission, and as confirmed by the nurse manager, the process was discussed with family/whanau and residents as part of the admission process. Complaints forms are accessible to staff, residents and family as required. The complaints register records the complaints, dates and actions taken.