Kiwiannia Care Limited - Granger Hose & Richard Seddon Hospital

Kiwiannia Care Limited - Granger Hose & Richard Seddon Hospital

Introduction

This report records the results of a Certification 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:Kiwiannia Care Limited

Premises audited:Granger House Rest Home & Richard Seddon Hospital

Services audited:Hospital services - Medical services; Hospital services - Geriatric services (excl. psychogeriatric); Rest home care (excluding dementia care)

Dates of audit:Start date: 3 February 2015End date: 4 February 2015

Proposed changes to current services (if any):Please note that individual dementia ‘top-up’ funding is provided by the DHB for one resident with dementia. Please also not – it is not Granger HOSE & Richard Seddon Hospital, it is Granger HOUSE & Richard Seddon Hospital

Total beds occupied across all premises included in the audit on the first day of the audit:57

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

Granger House provides residential care for up to 68 residents who require hospital and rest home level care. The facility is operated by KiwiAnnia Care Limited. Nine areas were identified as requiring improvement during this audit. The areas requiring improvement relate to:

the appointment of a permanent manager and clinical manager; quality and risk management documentation; timeliness of advising the Ministry of Health of an essential notification; staff in-service education; resident documentation including care planning documents and consents.

Residents and family interviewed were positive with regards to the care provided.

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. / Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk.

Information regarding the Health and Disability Commissioner's Code of Health and Disability Services Consumers' Rights (the Code), including the facility's complaints process and the Nationwide Health and Disability Advocacy Service, was accessible and is brought to the attention of residents’ (if able) and their families on admission to the facility. Residents and family members interviewed confirmed that their rights were met during service delivery, staff were respectful of their needs and communication was appropriate.

During interview residents and family confirmed that consent forms were provided and they were given whatever information they required prior to giving informed consent. However, improvements are required with some aspects of consent documentation. Residents and family reported time was provided if any discussions and explanations were required. Residents and family interviewed provided positive feedback on the care provided.

The executive director / acting manager is responsible for management of complaints and a complaints register is maintained.

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 medium or high risk and/or unattained and of low risk.

KiwiAnnia Care Limited is the governing body and is responsible for the service provided at Granger House and Richard Seddon Hospital. Planning documents reviewed included a business plan, a mission statement, values, and philosophy.

Systems are in place for monitoring the service and included regular monthly reporting by the executive director, who is also the acting manager, to the governing body. The previous facility manager left in July 2014 and a permanent replacement has not been found yet. Clinical supervision is also being provided by the executive director, who is an experienced registered nurse, because the assistant manager/clinical manager left the week prior to this audit. The provider is actively recruiting to find suitable replacements and improvements are required to this aspect of service delivery. Registered nurse cover was provided 24 hours a day seven days a week.

A new quality programme was implemented mid 2014 but has not been fully embedded. There was evidence that quality improvement data has been collected and collated. However, improvements are required because quality improvement data is not being comprehensively analysed to identify trends and improve service delivery. There is an internal audit programme in place and internal audits have been completed. Improvements are required because corrective action plans have not been consistently developed to address areas identified as requiring improvement. Resident meetings had not been held on a regular basis.

Adverse events are documented on accident/incident forms. Improvements are required with the timeliness of advising the Ministry of Health of essential notifications.

There are policies and procedures on human resources management and the validation of current annual practising certificates for health professionals who required them to practice has occurred. In-service education has been provided for staff although not all staff had attended core education sessions. Staff records provided evidence human resources processes have been followed and individual education records have been maintained.

There is a documented rationale for determining staffing levels and skill mix. The minimum number of staff on duty at any one time is one registered nurse and three care givers. The executive director/acting manager lives on-site and is available after-hours.

Resident information is entered into a register in an accurate and timely manner. Care staff are not consistently signing and dating all entries in residents’ clinical documentation and improvements are required.

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.

Each stage of service provision was developed with the resident and/or family input and coordinated to promote continuity of service delivery. Residents and family confirmed their input into care planning, access to a typical range of life experiences and choices and that interventions noted in their care plans were consistent with meeting their needs. Where progress was different from expected, the service responded by initiating changes to the care plan or recorded the changes on a short term care plan. There is an area requiring improvement around timeframes of assessments and care plans.

Planned activities were appropriate to the group setting. The residents and family confirmed satisfaction with the activities programme. The residents' files evidenced individual activities were provided either within group settings or on a one-on-one basis.

There was an appropriate medicine management system in place. Staff responsible for medicine management had current medication competencies. There were residents who self-administered medicines at the facility and did so according to policy and guidelines.

Food, fluid, and nutritional needs of residents were provided in line with recognised nutritional guidelines and additional requirements/modified needs were being met. There is a central kitchen and on site staff that provided the food service. The kitchen staff had completed food safety training.

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.

Accommodation for residents is provided in single bedrooms and several bedrooms have wash hand basins. Residents' rooms were observed to be of varying sizes and adequate personal space is provided in bedrooms.

Lounges, dining areas and various other alcoves are available for residents to sit. A large external area was available for sitting and shading is provided. An appropriate call bell system is available and security systems are in place.

Visual inspection provided evidence of sluice facilities, safe storage of chemicals, soiled linen and equipment. Protective equipment and clothing was provided and used by staff. Appropriate systems are in place to ensure the residents’ physical environment is safe and facilities are fit for their purpose.

Policies and procedures for waste management, cleaning and laundry, and emergency management are available and these were known by staff. All laundry is washed on site. Cleaning and laundry systems included appropriate monitoring systems to evaluate the effectiveness of these services.

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 restraint policy, procedures and the definitions of restraint and enabler were congruent with the restraint minimisation and safe practice standard. The approval process for enabler use was activated when a resident voluntarily requested an enabler to assist them to maintain independence and/or safety.

There was evidence the restraint was applied as last resort and recorded consent by family for the restraint use was obtained. The service provider's documentation evidenced a restraint register that recorded sufficient information to provide an auditable record of restraint 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 policies included guidelines on prevention and minimisation of infection and cross infection, and contained all requirements of the standard. New employees were provided with training in infection control practices and there was on-going infection control education available. Staff confirmed they were familiar with infection control measures at the facility.

The infection control surveillance data was sampled through resident records and collated infection reports. Information sampled confirmed that the surveillance programme was appropriate for the size and complexity of the services provided.

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 / 43 / 0 / 4 / 3 / 0 / 0
Criteria / 0 / 92 / 0 / 4 / 5 / 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 / Staff received training in the Code of Health and Disability Services Consumers’ Rights’ (the Code of Rights) at least annually. Staff education records reviewed confirmed this has occurred. Care staff were observed interacting respectfully and communicating appropriately with residents and their family. Staff encouraged residents to make choices demonstrating their knowledge of residents’ rights.
Residents and family members interviewed confirmed that services are provided with dignity and respect, privacy is maintained, and individual needs and rights are upheld. These findings were also confirmed in the completed resident and family survey questionnaires that were completed in September 2014.
Staff interviewed demonstrated an understanding of resident rights. Education records reviewed indicated that staff attended training in resident rights as part of their orientation as well as part of the on-going education programme; however not all care staff had attended on-going education (see criterion 1.2.7.5). Code of Rights education was last provided in March 2014.
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 / There were systems in place to ensure residents and where appropriate their family were being provided with information to assist them to make informed choices and give informed consent. In interviews, residents and family confirmed they were aware and understood the principles of informed consent, and confirmed informed consent information had been provided to them. Interviews with registered nurses (RNs) confirmed informed consent was discussed and recorded on the resident's admission to the facility. Written information on informed consent was included in the admission agreement. The residents' files evidenced signed informed consent forms. Residents' admission agreements evidenced resident or family and facility representative sign off.
The resident files had copies of enduring power of attorney (EPOA) documents, where EPOAs were recorded. The residents’ not for resuscitation orders were not completed correctly and this requires an improvement.
Standard 1.1.11: Advocacy And Support
Service providers recognise and facilitate the right of consumers to advocacy/support persons of their choice. / FA / There were appropriate policies regarding advocacy/support services in place that specify advocacy processes and how to access independent advocates. The executive director/acting manager advised a local minister tends to act as the resident advocate.
Care staff interviewed demonstrated an understanding of how residents can access advocacy/support persons. Care staff interviewed reported they had attended education on the Code of Rights, advocacy, and complaint management although review of staff records indicates that not all staff had attended in-service education on a regular basis (see 1.2.7.5).
Residents and family interviewed confirmed that advocacy support was available to them if required, and that information on how to access the Health and Disability Advocate was included in the information package they received on admission. Nationwide advocate details were displayed along with advocacy information brochures. Admission / pre-admission information provided information on advocacy, complaints and Code of Rights.