Rose Lodge Rest Home 2006 Limited - Rose Lodge Rest Home

Rose Lodge Rest Home 2006 Limited - Rose Lodge 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:Rose Lodge Rest Home 2006 Limited

Premises audited:Rose Lodge Rest Home

Services audited:Rest home care (excluding dementia care)

Dates of audit:Start date: 14 March 2016End date: 15 March 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:28

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

Rose Lodge is a 30 bed rest home in suburban Invercargill in Southland. Twenty-eight beds were occupied on the day of this certification audit, one of which was a person receiving respite care and another was occupied through carer support funding. The regional manager and owner have not changed since the previous certification and the facility manager has been in her role for approximately seven months.

This audit against the Health and Disability Services Standards included sampling processes, interviews, reviews of documents and observations of the environment and practices. Managers, staff, residents, family members and external health professional were involved. Policy documents, service delivery plans, staff competency and training processes and quality and risk system documentation were reviewed.

The resultant information confirmed that the systems and processes in place at Rose Lodge are meeting the requirements of the standard and the needs of the residents are being met with high levels of satisfaction. There were no corrective actions identified. Three areas of quality improvement within implementation of the quality and risk management system were evident. An increased number of internally generated corrective actions have resulted in positive changes. There has been a significant increase in the number of quality improvement projects.

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 admission process for residents into the facility is planned and timely. Information is provided prior to admission to ensure residents and families have time to consult with others and are fully informed. Time and privacy for discussion to occur is provided.

Completed incident/accident reports showed that open disclosure is occurring and this was confirmed by relatives and residents who talk of being fully informed and say the manager and staff maintain open dialogue with them at all times. An interpreter policy with contact details is in place, however there has not been any requirement for such services.

During the audit staff were observed to respect residents’ rights during service delivery, allowing for personal choices, acknowledging and supporting cultural, spiritual, emotional, individual rights and beliefs and encouraging independence.

Residents and family members interviewed reported that staff are very respectful of their needs, that communication is consistent and appropriate and they are given time for discussions to take place with staff and family/whanau. They have a clear understanding of their rights and the facility’s processes if these are not met.

Information about the Health and Disability Commissioner’s Code of Health and Disability Services Consumer Rights (the Code), including the facility’s complaints process and the Nationwide Health and Disability Advocacy Service, was on display at the entrance to the facility and is available in admission packs and on request.

Information about the complaints process and a complaints and suggestion form is available. Complaints are being investigated and followed up until resolution. A register of complaints is in place and shows that verbal expressions of dissatisfaction are also being registered.

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. / All standards applicable to this service fully attained with some standards exceeded.

The purpose, scope and values of the organisation are available and are relevant. Goals and objectives sit within an updated business plan. Both the facility and regional managers are suitably qualified and experienced and continue to update their skills.

Organisational policies and procedures are document controlled and have been reviewed and updated as required. Comprehensive quality and risk management plans align with the organisational policy documents. These plans are being implemented at a level of continuous improvement as a wide range of staff, including care assistants, have been trained and involved in different aspects of quality management, internal audits and review processes. This has resulted in a culture shift around attitudes about quality and risk systems and there were multiple examples of quality improvement projects in place, many of which have resulted from corrective actions identified by staff, other than managers. Data is being analysed and corrective action plans developed from all expected components of a quality and risk system including internal audits, the management of complaints and incidents, reviews of restraint and infection control and health and safety reviews, for example.

Professional qualifications have been validated. Safe and accountable recruitment processes are ensuring suitable staff are being employed. A comprehensive orientation programme for new staff is being implemented and a diverse internal training programme is being maintained. Staff are encouraged to undertake suitable external training opportunities.

Staff are being rostered at safe levels according to a master that has been created according to a staffing policy. Rostering takes staff competencies into account. Additional rostered hours of staff are added or reduced according to changes in acuity levels.

Residents records are being entered in a timely manner and meet the requirements of the standard and the contract. Archived records were stored securely.

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.

Services are being delivered according to service delivery plans that are developed and reviewed by a registered nurse (RN). Assessment tools are used and residents and relatives are consulted. This facility has commenced using the interRAI assessment programme. The RN completes the assessment from which an individualised, detailed care plan is developed. Regular review occurs to reflect the resident’s assessed needs. There has been a comprehensive implementation and review of care planning and evaluation process with input from residents, families/whanau, allied health professionals and the wider community.

Short term care plans are developed when issues arise within the review time frame. Staff were observed providing services in a respectful and dignified manner, reflecting the care plan content. This was also confirmed in resident and family/whanau interviews.

Planned activities occur that are meaningful to the consumer as part of the service delivery plan and are appropriate to their needs, age, culture and the setting of the service.

Medicines are being managed according to policies, procedures and guidelines for safe practice. Those administering medicines have been assessed as competent to do so.

Two general practitioners (GPs) were interviewed during the audit and confirmed the facility provides a good standard of care and that assessments and service delivery is appropriate, timely and in line with treatment recommendations.

Whole foods and home prepared cooking contribute to ensuring the nutritional needs of residents are met. A rotating menu has been reviewed by a dietitian, and for any resident with special dietary needs, these have been accommodated. Food is stored safely, twice daily temperature monitoring is occurring and stock rotation is occurring in the fridges, freezers and pantry.

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.

Waste is being managed through the use of private contractors and council collections. Personal protective equipment is available for staff and its use is monitored by the infection control officer.

A maintenance person is responsible for the management of the buildings and equipment. The facility has a current building warrant of fitness, a maintenance schedule is being adhered to and repairs are undertaken as required. Electrical checks have been completed, equipment is being calibrated and water temperatures are monitored. The external areas are safe and gardens are well maintained.

There are adequate communal toilets and showers as well as a shared ensuite between two rooms. All rooms have a wash basin. Residents, including those with walking aids, are able to easily mobilise around their bedrooms the communal lounge and the dining room.

Cleaning and laundry is undertaken according to schedules. Chemicals are locked away and staff have been trained on their use.

A fire evacuation plan is in place, fire drills occur every six months, fire safety systems and equipment are being checked and emergency management training provided. The contents of an emergency kit are being checked annually and emergency management and security systems are in place. A call bell system is operational.

Night store heating units are in all residents’ rooms and throughout the facility. A heat pump and bathroom fan heaters are in place. Room temperatures are checked monthly. Windows in all resident-designated areas have security latches and are openable.

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.

Policies and procedures on restraint minimisation and safe practice are accessible to staff. These include a definition of enablers and descriptions of any use of them at this facility. Staff undertake related training at orientation and biennially. The facility manager is the restraint coordinator and is responsible for reporting on restraint and enabler use at quality and risk meetings. There were no restraints or enablers in use at the time of audit.

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.

There is a documented infection prevention and control (IPC) programme which contains all requirements of the Standards. The infection control officer is supported by the facility manager and registered nurse (RN). The infection control officer reports to the manager and at the monthly quality meeting. Feedback is also provided to staff at their monthly meeting.

Records sighted and interviews demonstrated that staff have a clear understanding of what is required to implement the documented infection prevention and control programme (IPC) and reporting requirements. The staff are able to gain advice from a variety of external sources if required, including the Public Officer of Health in Invercargill. The GPs are also consulted regarding individual resident’s infections.

Infection control surveillance is occurring. The incidence and range of infections is low. The numbers and type of infections are analysed at the organisational level and at the individual resident level with the aim of minimising infections.

All staff receive IPC education as part of orientation and at least annually. There is a focus on education and prevention. Residents and family/whanau are educated in IPC practices as required for specific practices and when visiting the facility.

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 / 44 / 0 / 0 / 0 / 0 / 0
Criteria / 3 / 89 / 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 / Interviews with residents and family/whanau members and a review of seven rest home care records and observation during the audit verified that staff have knowledge and understanding of consumer rights and integrate them into every day practice. Records reviewed confirmed staff training occurs initially, during orientation and annually.
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 / There are appropriate informed consent policy and procedures. These were reflected in documentation reviewed and included signed admission agreements and advance directives, written consents for transport, influenza vaccination, outings, photographs, names on doors and care provisions. Where applicable, power of attorney documentation was provided and accompanying signatures.
Staff during interview demonstrated knowledge of informed consent practices. Residents and family/whanau confirmed and provided examples that staff gain consent on a daily basis.
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 are policies that include the right of residents to have an advocate or support person of their choice. Residents and family/whanau interviewed confirmed that family/whanau and support persons are included in discussions relating to care provision. Staff interviewed were aware of the residents’ rights to have a support person of their choice at any time.