Kiwi Elderly Care Limited - Kimberley Rest Home

Kiwi Elderly Care Limited - Kimberley Rest Home

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 Health and Disability Auditing New Zealand 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:Kiwi Elderly Care Limited

Premises audited:Kimberley Rest Home

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

Dates of audit:Start date: 15 February 2016End date: 16 February 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.

General overview of the audit

Kimberley rest home is certified to provide rest home and dementia level care for up to 24 residents. On the day of audit, there were 18 residents. An experienced and qualified non-clinical manager who has been in the role since October 2015, currently manages the service. The facility owner, who is a registered nurse and works in the role of clinical nurse manager, supports the manager. The quality management system in place is designed to identify opportunities for improvement. Residents and families interviewed were complimentary of the service they receive. Staff turnover is reported as low.

A provisional audit was conducted to assess a prospective new owner for Kimberley rest home and to assess the current status of the service prior to purchase. This audit was conducted against the health and disability service standards and the district health board contract. The audit process included a review of existing policies and procedures, the review of resident and staff files, observations and interviews with residents, family members, staff and management. The prospective owner was also interviewed.

The audit has identified that improvements are required around admission agreements and informed consent, incident reporting, staff files, education and training, staff entries into resident notes, aspects of resident assessments, care planning, interventions and evaluations, medication documentation, dietitian review of the menu, kitchen staff training, hot water temperatures, equipment checks, and external hazards.

Consumer rights

The staff at Kimberley rest home strives to ensure that care is provided in a way that focuses on the individual, and residents' autonomy is valued. Information about the code of rights and services is easily accessible to residents and families. Care plans accommodate the choices of residents and/or their family/whānau. Complaints and concerns have been managed and a complaints register is maintained.

Organisational management

The prospective owner was interviewed to establish preparedness in owning and operating Kimberley rest home. This person is new to the aged care industry. Their intention is to retain and maintain the current quality systems and processes, policies and procedures, existing staff and management.

The current quality and risk management programme includes service philosophy, goals and a quality planner. Quality activities are conducted and this generates improvements in practice and service delivery. Corrective actions are implemented and followed through, and communicated to staff. Health and safety policies, systems and processes are implemented to manage risk. Discussions with families identified that they are fully informed of changes in health status. Staff advised there is an orientation programme that provides new staff with relevant information for safe work practice. Human resource policies are in place including a documented rationale for determining staffing levels and skill mixes. A roster provides sufficient and appropriate coverage for the effective delivery of care and support. Advised by the prospective owner, that rosters, staffing levels, and policies and procedures will remain as the status quo following transition to new ownership.

Continuum of service delivery

The registered nurse is responsible for each stage of service provision at Kimberley rest home. The InterRAI assessment tool has been utilised. Referral to other health and disability services occurs as required. Families and residents interviewed were very supportive of the care provided. Two activities coordinators provide a range of activities that are suitable for rest home and dementia residents. There are policies and procedures to guide staff in the safe implementation of all medicine management. Nutrition and safe food systems are appropriately managed on site.

Safe and appropriate environment

There is a current building warrant of fitness. Furniture and fittings are selected with consideration to residents’ abilities and functioning. Furniture is appropriate to the setting and arranged to enable residents to mobilise. The service has waste management policies and procedures for the safe disposal of waste and hazardous substances. Chemicals are labelled and there is appropriate protective equipment and clothing for staff. Laundry and cleaning processes are monitored for effectiveness. The service has implemented policies and procedures for fire, civil defence and other emergencies. There is staff on duty with a current first aid certificate. General living areas and resident rooms are appropriately heated and ventilated. Residents have access to natural light in their rooms and there is adequate external light in communal areas.

Restraint minimisation and safe practice

There are restraint minimisation and safe practice policies applicable to the service. Guidelines on the use of restraints policy ensures that enablers are voluntary, the least restrictive option and allows residents to maintain their independence. There are currently no residents using restraint or enablers in the rest home or in the dementia unit.

Infection prevention and control

Infection control management systems are in place to minimise the risk of infection to consumers, service providers and visitors. The infection control programme is implemented and meets the needs of the organisation and provides information and resources to inform the service providers. Documented policies and procedures are in place for the prevention and control of infection and reflect current accepted good practice and legislative requirements. Infection control education is provided to all service providers as part of their orientation and as part of the ongoing in-service education programme. The type of surveillance undertaken is appropriate to the size and complexity of the organisation. Standardised definitions are used for the identification and classification of infection events. Results of surveillance are acted upon, evaluated and reported to relevant personnel in a timely manner.

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 / 34 / 0 / 4 / 7 / 0 / 0
Criteria / 0 / 80 / 0 / 6 / 7 / 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 / Health and Disability Commissioner (HDC) Code of Health and Disability Services Consumers’ Rights (the Code) policy and procedure is implemented. Discussions with staff (five caregivers, one activities coordinator, the clinical nurse manager and the manager) confirm their familiarity with the Code. Interviews with five rest home residents and three relatives (one rest home and two dementia) confirm the services provided are in line with the Code of rights.
The provision of Code of rights and advocacy training is required (link #1.2.7.5). The prospective owner was not familiar with the Code and is therefore, required to undertake training (link #1.2.7.5).
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. / PA Moderate / The service has an informed choice and consent form. Discussions with staff and management confirmed that consents are sought in the delivery of personal cares. Resident and family interviews confirmed that residents were able to make choices. Advanced directives reviewed in the sample of resident files (five) were not all signed appropriately. Admission agreements were not evident in all resident 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 / An advocacy policy and procedure includes how staff can assist residents and families to access advocacy services. Contact numbers for advocacy services are included in the policy, in the resident information folder and in advocacy pamphlets that are available at reception.
Residents’ meetings include discussing previous meeting minutes and actions taken (if any) before addressing new items. The residents’ files include information on residents’ family/whānau and chosen social networks.
Residents are provided with a copy of the code and Nationwide Health and Disability Advocacy services pamphlets on entry. Discussions with relatives identify that the service provides opportunities for the family/EPOA to be involved in decisions.
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 resident information pack states that visiting can occur at any reasonable time. Interviews with residents and relatives confirm that visiting can occur at any time. Family members were seen visiting on the days of the audit. Key people involved in the resident’s life are documented in the care plans.
Discussions with residents and relatives verify that they are supported and encourage, to remain involved in the community. Kimberley rest home staff support ongoing access to community and entertainers are invited to perform at the facility.
Standard 1.1.13: Complaints Management
The right of the consumer to make a complaint is understood, respected, and upheld. / FA / A complaints policy and procedure is in place. Residents/family can lodge formal or informal complaints through verbal and written communication, resident meetings and complaint forms.
Information on the complaint’s form includes the contact details for the Health and Disability Advocacy Service.
Interviews with residents and relatives confirmed they were familiar with the complaints procedure and state any concerns or issues were addressed.
The complaints log/register includes the date of the incident, complainant, summary of complaint, any follow-up actions taken and signature when the complaint is resolved. Complaints for 2015 were reviewed. A full investigation of all complaints has been conducted and resolutions obtained which included staff performance management as required. Complainants are advised in writing of the outcomes of the investigations within the required timeframes. Advised that resident meetings are an open forum for residents to air any concerns or issues which are then dealt with in a timely manner.
Standard 1.1.2: Consumer Rights During Service Delivery
Consumers are informed of their rights. / FA / The service provides information to residents including the Code of rights, complaints and advocacy information. Information is given to the family or the enduring power of attorney (EPOA) to read to and/or discuss with the resident. Interviews with residents and relatives identify they are informed about the code of rights. The manager and clinical nurse manager provide an open-door policy for concerns or complaints.
Resident meetings have been held to provide the opportunity to raise concerns in a group setting. A resident satisfaction survey has been conducted. The survey includes questions relating to the complaints process and residents rights, with respondents reporting they were overall satisfied or very satisfied.
Advocacy pamphlets, which include contact details, are included in the information pack and are available at reception. The service has an advocacy policy that includes a definition of advocacy services, objectives and process/procedure/guidelines.
Standard 1.1.3: Independence, Personal Privacy, Dignity, And Respect
Consumers are treated with respect and receive services in a manner that has regard for their dignity, privacy, and independence. / FA / The service has policies that align with the requirements of the Privacy Act and Health Information Privacy Code. Staff were able to describe the procedures for maintaining confidentiality of resident records. Staff sign house rules and a code of conduct, at commencement of employment.
The service has a philosophy that promotes quality of life, involves residents in decisions about their care, respects their rights and maintains privacy and individuality.
Church services are held twice a month. Contact details of spiritual/religious advisors are available to staff. Residents and relatives interviewed confirm the service is respectful.
Residents’ files include their cultural and/or spiritual values when identified by the resident and/or family. Discussions with residents confirm that they are able to choose to engage in activities and access community resources. Staff education and training on abuse and neglect has not been provided in the past two years (link #1.2.7.5).
Standard 1.1.4: Recognition Of Māori Values And Beliefs
Consumers who identify as Māori have their health and disability needs met in a manner that respects and acknowledges their individual and cultural, values and beliefs. / FA / There is a Māori heath plan and an individual’s values and beliefs policy that includes cultural safety and awareness. Discussions with staff confirm their understanding of the different cultural needs of residents and their whānau. There is information and websites provided within the Māori health plan to provide quick reference and links with local Māori. Interviews with staff confirm they are aware of the need to respond appropriately to maintain cultural safety. Policies include guidelines about the importance of whānau. Cultural awareness training has not been provided for staff in the last 2 years (link 1.2.7.5).
Standard 1.1.6: Recognition And Respect Of The Individual's Culture, Values, And Beliefs
Consumers receive culturally safe services which recognise and respect their ethnic, cultural, spiritual values, and beliefs. / FA / Care planning includes consideration of spiritual, psychological and social needs. Residents interviewed indicate that they are asked to identify any spiritual, religious and/or cultural beliefs. Relatives report that they feel they are consulted and kept informed. Family involvement is encouraged, for example invitations to residents meetings and facility functions. The service provides a culturally appropriate service by identifying the individual needs of residents during the admission and care planning process as reported by the registered nurse. Care plans reviewed include the residents’ social, spiritual, cultural and recreational needs.