Social Service Council of the Diocese of Christchurch - Bishopspark

Social Service Council of the Diocese of Christchurch - Bishopspark

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 byHealth 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:Social Service Council of the Diocese of Christchurch

Premises audited:Bishopspark Retirement Village

Services audited:Rest home care (excluding dementia care)

Dates of audit:Start date: 11 May 2017End date: 11 May 2017

Proposed changes to current services (if any):Increase the capacity of the service by utilising seven more studio units to provide rest home level care.

Total beds occupied across all premises included in the audit on the first day of the audit:27

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

Bishopspark Retirement Village is part of the Social Services Council of the Diocese of Christchurch (Anglican Living) organisation. The service provides rest home level care for up to 31 residents. On the day of the audit there were 27 residents. The service is managed by an experienced manager who is a registered nurse (RN). The manager is supported by a registered nurse and care staff.

This certification audit was conducted against the relevant Health and Disability Standards and the contract with the district health board. The service has been assessed as part of this audit as suitable to provide rest home level care in a further seven studio units. The audit process included a review of policies and procedures, the review of resident’s and staff files, observations and interviews with residents, relatives, general practitioner (GP), staff and management.

The residents and relatives interviewed spoke positively about the care and support provided.

This audit identified that there were no areas for improvement.

The service has achieved continuous improvement ratings around: quality initiatives implemented from data analysis, infection control and activities.

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.

Bishopspark Retirement Village practices in accordance with the Health and Disability Commissioner (HDC) Code of Health and Disability Services Consumers' Rights (the Code). There is information available about the Nationwide Health and Disability Advocacy Service. Staff, residents and family confirm that the service is respectful of individual needs including cultural and spiritual beliefs. Cultural training is provided and individual values and beliefs are considered on admission and continuing through the care planning process. There is an open disclosure policy that staff understand. Family/friends are able to visit at any time and ongoing involvement with community activity is supported.

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 organisation has an annual business and quality plan in place with annual quality objectives. Quality information is reported to monthly quality/health and safety/staff meetings. The service is actively involved in ongoing quality projects to improve outcomes and service delivery for the residents. The service has comprehensive policies/procedures to provide rest home level of care. There is an orientation programme in place. There is a staffing policy that includes a documented rationale for determining staffing levels and skill mixes for safe service delivery. The staffing roster indicates there are adequate numbers of staff and registered nurses on duty to safely deliver care within a timely manner. A two-yearly rotating in-service education calendar is implemented.

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

Residents are assessed prior to entry to the service. A baseline assessment is completed upon admission and an interRAI assessment within three weeks. Long-term care plans are developed by the registered nurse, who also has the responsibility for maintaining and reviewing the care plans.

InterRAI assessment tools and service monitoring forms are used to assess the level of risk and ongoing support required for residents. Care plans are evaluated six-monthly or more frequently when clinically indicated. The service facilitates access to other medical and non-medical services. Referral documentation is maintained on resident files.

The activity programme is varied and reflects the interests of the residents, including community interactions.

There are comprehensive medication management policies that direct staff in terms of their responsibilities in each stage of medication management. Competencies are completed. Medication profiles are up to date and reviewed by the general practitioner three-monthly or earlier if necessary.

The food service is provided by a contracted catering company. The menu is designed and reviewed by a registered dietitian. Residents' individual needs are identified. There is a process in place to ensure changes to residents’ dietary needs are communicated to the off-site kitchen. Regular audits of the kitchen occur.

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.

The service displays a current building warrant of fitness. The building is two storied with a lift and stairways between floors. Proactive and reactive maintenance is carried out. Furniture and fittings are selected with consideration to residents’ abilities and functioning. Residents can and do bring in their own furnishings for their rooms. The service has policies and procedures for management of waste and hazardous substances and incidents are reported on in a timely manner. Staff receive training and education to ensure safe and appropriate handling of waste and hazardous substances. Documented policies and procedures for the cleaning services are implemented with monitoring systems in place. Laundry is completed off-site by an external commercial laundry service. Policies and procedures are in place for essential, emergency and security services, with adequate supplies should a disaster occur. There is always a staff member on duty with a current first aid certificate.

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.

Staff regularly receive training around restraint minimisation and the management of challenging behaviour. The service has appropriate procedures and documents for the safe assessment, planning, monitoring and review of restraint and enablers. A register is maintained by the restraint coordinator. There were no enablers or restraints in use at the time of the audit. The registered nurse is the restraint coordinator.

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.

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. Documentation evidences that relevant infection control education is provided to all staff as part of their orientation and also as part of the ongoing in-service education programme. The 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. There have been no outbreaks since the previous audit.

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 / 90 / 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 / Bishopspark Retirement Village practices in accordance with the Health and Disability Commissioner (HDC) Code of Health and Disability Services Consumers' Rights (the Code) and posters of the Code are displayed throughout the facility. The policy relating to the Code is implemented and staff are able to describe how the Code is incorporated in their everyday delivery of care. Staff receive training about the Code during their induction to the service, and through the in-service education and training programme. Interviews with staff (three caregivers, one registered nurse (RN), one activities coordinator, one maintenance person and one kitchen manager) reflects their understanding of the key principles of the Code.
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 / The service has policies and procedures relating to informed consent and advanced directives. All six resident files reviewed include signed informed consent forms and advanced directive instructions. Staff are aware of advanced directives. For those residents who are not mentally competent to make a decision regarding resuscitation and no previous resuscitation instructions are in place, there is evidence of GP discussion with family and a medical decision regarding resuscitation status is documented by the GP. Enduring power of attorney evidence is sought prior to admission and activation documentation is obtained and both are filed with the admission agreements. Where legal processes are ongoing to gain EPOA, this is recorded, as are letters of request to families for the supporting documentation. Admission agreements are signed by the resident or nominated representative. Discussion with residents and families identifies that the service actively involves them in decision making.
Standard 1.1.11: Advocacy And Support
Service providers recognise and facilitate the right of consumers to advocacy/support persons of their choice. / FA / Residents and families are provided with information about the Nationwide Health and Disability Advocacy Service. Advocacy pamphlets are displayed in the entrance to the facility. Caregivers interviewed are aware of the resident’s right to advocacy services and how to access the information. Resident advocates are identified on admission. Interviews with residents and relatives confirms that they are aware of their right to access advocacy.
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 service maintains key linkages with other community and external groups including churches and schools. Residents are invited to community functions and events. Visiting arrangements are suitable to residents and family/whānau. Families and friends are able to visit at times that meet their needs. Discussion with staff, residents and relatives, determined that residents are supported and encouraged to remain involved in the community.
Standard 1.1.13: Complaints Management
The right of the consumer to make a complaint is understood, respected, and upheld. / FA / The complaints policy and procedures have been implemented and residents and their family/whānau have been provided with information on admission. Complaint forms are available and staff are aware of the complaints process and to whom they should direct complaints. A complaints folder has been maintained. Five complaints were made in 2016 and no complaints have been received in 2017 year to date. Follow-up letters, investigation and outcome is documented. Quality improvements have been implemented and any changes required have been made as a result of the complaint. Residents and family members advise that they are aware of the complaints procedure and how to access forms.
Standard 1.1.2: Consumer Rights During Service Delivery
Consumers are informed of their rights. / FA / Details relating to the Code are included in the resident information pack that is provided to new residents and their family. The manager or RN discusses aspects of the Code with residents and their family on admission. Discussions relating to the Code are held during the six-monthly resident/family meetings. Four residents and four relatives interviewed report that the residents’ rights are being upheld by the service and that they receive sufficient information to be able to make informed choices on matters that affect them.
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 / Residents are treated with dignity and respect. Privacy is ensured and independence is encouraged. Residents and relatives are positive about the service in relation to their values and beliefs being considered and met. Residents' files and care plans identify residents preferred names. Values and beliefs information is gathered on admission with family involvement and is integrated into the residents' care plans. Spiritual needs are identified and church services are held. There is a policy on abuse and neglect and staff received training during September 2016. The service has an Anglican chaplain who is contracted for eight hours a week.