Elders Paradise Limited

Elders Paradise Limited

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 byHealth Audit (NZ) 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:Elders Paradise limited

Premises audited:Janelle Rest Home

Services audited:Rest home care (excluding dementia care)

Dates of audit:Start date: 22 July 2016End date: 22 July 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:18

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

Janelle Rest Home provides rest home level of care for up to 21 residents. At the time of audit there were 18 residents all over the age of 65 years.

This unannounced surveillance audit was conducted against the relevant Health and Disability Services Standards and the service’s contract with the district health board (DHB). The audit included follow up on previously identified areas for improvement and specific follow up requests from the DHB. The audit process included the onsite audit and the review of documentation, observations and interviews. Interviews were conducted with management, clinical and non-clinical staff, residents, family/whanau and a general practitioner.

The service is managed by one of the owners, who is supported by a registered nurse who provides clinical oversight.

There were three areas of improvement required at the previous audit. These related to job descriptions, evaluation of care and the infection control coordinators ongoing education. These have now been addressed. There are no new areas for improvement or systemic issues identified in the surveillance criteria.

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 provides information to residents and family in an open and honest manner. All residents are able to effectively communicate with the staff.

The complaints management system and timeframes for dealing with complaints are compliant with legislative requirements. There is a complaints register that contains all complaints, dates and actions taken to resolve any issues identified.

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 is a family owned business, with one of the owners being the manager. The goals, vision, philosophy and direction of the organisation are clearly documented in business and quality planning records. The services are planned to meet the needs of the residents. There is a mix of people with suitable business management and clinical knowledge to manage the service.

The quality and risk management system is documented throughout various organisational records. The quality and risk management plan is reviewed on an annual basis and monitored through the internal audit programme and review of quality data. Quality data is collected, collated and analysed each month. Corrective actions are implemented as required.

Policies and procedures are developed by an external aged care consultant and personalised to the service. Polices reflect current accepted best practice and legislation.

The service reports any serious harm or adverse events to the relevant authorities. The organisation incident and accident reporting system is used to capture any adverse events. The analysis of the adverse events is used to make improvements to service delivery.

There is an appropriate process for the employment, orientation and ongoing education of the staff. The staffing skill mix and ratio meets the contractual requirements for rest home level of care.

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.

The registered nurse is responsible for the development of care plans with input from the residents, staff and family member representatives. Care plans and assessments are developed and evaluated within the required time frames that safely meet the needs of the resident and contractual requirements.

Planned activities are appropriate to the residents assessed needs and abilities. Residents expressed satisfaction with the activities programme in place.

There is a medication management system in place and medication is administered by staff with current medication competencies. All medication charts are reviewed by the GP every three months.

Nutritional needs are provided in line with nutritional guidelines and residents with special dietary needs are catered for.

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.

There is a current building warrant of fitness. There have been no changes to the layout of the service since the last audit.

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 clear and comprehensive documented guidelines on the use of restraints, enablers and challenging behaviours. There were no residents using restraint or enablers at the time of the audit. Staff receive restraint and enabler education.

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 number and types of infections are recorded each month. The infection surveillance data is analysed and actions are implemented to reduce cross infection or the recurrence of infections. Staff and management are informed of any infections or trends that have been identified.

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 / 18 / 0 / 0 / 0 / 0 / 0
Criteria / 0 / 41 / 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 1.1.13: Complaints Management
The right of the consumer to make a complaint is understood, respected, and upheld. / FA / The complaints forms are accessible and displayed at the sign in area at the entrance to the facility. The complaints policy complies with Right 10 of the Code. The residents and family whanau reported they would have no problem if they wished to make a complaint. They felt that the staff are approachable and act on concerns that they have.
The complaints register records the date, complainant, issue, solution and sign off when closed. There are two verbal complaints recorded in 2016, with these being addressed within time frames outlined in Right 10 of the Code. The issues related to suspected missing clothing items and noise at night. The register records satisfactory resolution for the residents. The staff demonstrated understanding of the complaints management processes.
Standard 1.1.7: Discrimination
Consumers are free from any discrimination, coercion, harassment, sexual, financial, or other exploitation. / FA / The previous audit identified an area for improvement to ensure that there are signed job descriptions. This is now addressed with all five staff files reviewed evidencing signed job descriptions. The job descriptions and employment agreements outline the required professional boundaries. The registered nurse (RN) has completed the required nursing council code of conduct training. The service has conducted staff education on maintaining professional boundaries. The residents and family whanau reported that they do not have any concerns regarding discrimination.
Standard 1.1.9: Communication
Service providers communicate effectively with consumers and provide an environment conducive to effective communication. / FA / The adverse event forms sighted evidenced that open disclosure is maintained. The residents and family/whanau reported they are kept fully informed about any concerns or issues. The management and staff demonstrated an understanding of how to maintain open disclosure and how to access interpreting services.
The residents and staff are able to effectively communicate with each other. The service has accessed interpreting services when residents who do not have English as their first language and have specialist reviews at the DHB.
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 is a family owned business, with one of the owners being the manager. They have owned and managed the service for two and a half years. The manager undertakes overall financial responsibilities and has a registered nurse employed for clinical oversight. The manager has a background in accountancy and small business management. The service manager is a member of an Aged Care Association and receives regular updates and ongoing education on issues related to the management of an aged care facility.
Services are planned to meet the needs of those assessed as requiring rest home level of care only. The residents and family/whanau interviewed all reported satisfaction with the services, supports and care provided.
There is a business plan that includes the goals and objectives of the organisation. The mission statement describes the aim to provide a quality and homelike environment to meet the needs of the individual residents. The business plan is reviewed annually, which was last conducted in April 2016. The goals of the business plan are also monitored at least monthly through the quality and risk management system. The service also documents specific aims and ambitions for the upcoming year that are over and above the targets in the business plan.
The registered nurse (RN) has clinical oversight for resident care and clinical services and has a current practicing certificate (sighted). The RNs signed job description outlines their roles, responsibility and accountabilities. The RN has over six years’ experience in aged care and has previously been in aged care management roles. They have attended over eight hours’ education in the past 12 months related to aged care management and clinical knowledge. The RN is enrolled in post graduate education in gerontology.
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 combined quality and risk plan details quality goals and objectives. These incorporate efficiency, effectiveness, safety, responsiveness and accountability to meet health and disability service provision. The goals include resident focus, provision of effective programmes, contractual requirements, quality and risk management for all aspects of service delivery and continuous improvement. Each of the goals records objectives and management controls and how they are to be measured. The staff demonstrated an understanding of how they contribute to implementing the quality and risk management systems.
Quality and risk systems are monitored through a process of internal audits, meetings, surveys, training attendance, advice from external advisors and checklists. There is monthly analysis of all quality data. When shortfalls are identified corrective action processes are implemented. The corrective action process includes a cycle of monitoring, assessment, action, evaluation and feedback. An audit action form is maintained that documents and summarises the satisfactory completion of corrective actions. The results of audits, surveys, investigations and other quality data is communicated to all appropriate staff, residents, family and key stakeholders. Regular staff meetings provide a forum for discussing quality issues. The meeting minutes and staff interviews confirm this.
The policies are developed by an aged care consultant and are personalised to the service. Policies are reviewed on an annual basis or sooner if there are changes in best practice or legislation. The age care consultant keeps the service updated on any changes. When policies are updated, changed or added, these are discussed at staff meetings. Staff only have access to most recent version of policies. All policies and procedures are controlled to ensure currency.
The quality and risk plan details the risks, current controls, and ongoing actions required to limit exposure to risk. The risk management plan is also linked to the business plan in order minimise operational risks. The hazard register sighted documents the hazard, potential harm and risk rating. If it is a significant hazard, actions are implemented to minimise the risk of occurrence and frequency of monitoring is increased.