Sunrise Healthcare Limited - West Harbour Gardens

Sunrise Healthcare Limited - West Harbour Gardens

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: Sunrise Healthcare Limited

Premises audited: West Harbour Gardens

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

Dates of audit: Start date: 4 July 2017 End date: 5 July 2017

Proposed changes to current services (if any): A provisional audit was conducted to assess a prospective new owner for the facility and to assess the current status of the service prior to purchase.

Total beds occupied across all premises included in the audit on the first day of the audit: 55

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.

General overview of the audit

West Harbour Gardens residential care is part of the TerraNova homes. The service currently provides care for up to 74 residents. The service is certified to provide hospital (medical, geriatric) rest home and residential – disability level care. On the day of the audit, there were 55 residents. Two rooms were being refurbished at the time of audit and were unoccupied.

The facility manager (RN) has many years’ experience in aged care management. The clinical coordinator (RN) has been in the role for one year and has worked in aged care for the last four years.

A provisional audit was conducted to assess a prospective new owner for the facility 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 a GP, residents, family members, staff and management. The prospective owner was interviewed on the first day of the audit.

The prospective provider owns a 40-bed hospital in Auckland. The prospective provider intends to continue with the quality processes as set out in the previous provider’s quality plan. The current facility manager and the Terra Nova clinical quality and risk advisor will provide orientation and induction to processes and the clinical coordinator will stay on in charge of the clinical services. The prospective provider (chief executive officer) is a qualified chartered accountant and will oversee financial matters. Reporting processes will stay in place but reports will be to the new directors. The prospective providers’ transition plan is to keep all operational processes the same with only the directors changing. The current owners have entered into contractual arrangements where they will provide Vendor Support for 20 working days following completion of the sale and provide core system services for up to 6 months from completion (at the election of the Purchaser) to allow an ordered transition of these services.

One improvement is required around timely completion of InterRAI assessments.

The facility has achieved a continuous improvement around infection control surveillance.

Consumer rights

West Harbour Gardens endeavours to ensure that care is provided in a way that focuses on the individual, values residents' quality of life and maintains their privacy and choice. Staff demonstrate an understanding of residents' rights and obligations. This knowledge is incorporated into their daily work duties and caring for the residents. Residents receive services in a manner that considers their dignity, privacy and independence. Written information regarding consumers’ rights is provided to residents and families. Cultural diversity is inherent and celebrated. Evidence-based practice is evident, promoting and encouraging good practice. There is evidence that residents and family are kept informed. The rights of the resident and/or their family to make a complaint is understood, respected and upheld by the service. Care plans accommodate the choices of residents and/or their family/whānau. Complaints processes are implemented, and complaints and concerns are actively managed and well documented.

Organisational management

Services are planned, coordinated, and are appropriate to the needs of the residents. A facility manager and clinical coordinator are responsible for the day-to-day operations of the facility. Goals are documented for the service with evidence of annual reviews. A risk management programme is in place, which includes managing adverse events and health and safety processes.

West Harbour Gardens is implementing the organisational quality and risk management system that supports the provision of clinical care. Key components of the quality management system link to a number of meetings. An annual resident/relative satisfaction survey is completed and there are regular resident/relative meetings. Quality and risk performance is reported across the facility meetings and to the organisation's management team. Interviews with staff and review of meeting minutes/quality corrective action forms/education, demonstrate a culture of quality improvements.

Residents receive appropriate services from suitably qualified staff. Human resources are managed in accordance with good employment practice. A comprehensive orientation programme is in place for new staff. Ongoing education and training for staff is in place. Registered nursing cover is provided 24 hours a day, seven days a week.

Continuum of service delivery

There is a comprehensive admission package on all services and levels of care provided. The registered nurses are responsible for each stage of service provision. A registered nurse assesses and develops the care plan documenting supports, needs, outcomes and goals with the resident and/or family/whānau input. Care plans viewed in resident records demonstrated service integration and were reviewed at least six-monthly. Resident files included the general practitioner, specialist and allied health notes. Residents and families commented positively on the care received at West Harbour Gardens Residential Care.

Medication policies reflect legislative requirements and guidelines. Registered nurses are responsible for administration of medicines and complete annual education and medication competencies. The medicine charts reviewed meet prescribing requirements and were reviewed at least three-monthly.

A diversional therapist oversees the activity programme for the rest home and hospital residents including the younger people. An activity coordinator is employed to assist with the delivery of the programme. The programme includes community visitors and outings, entertainment and activities that meet the individual recreational, physical, cultural and cognitive abilities and preferences for each resident group including the needs of younger people.

All meals and baking are done on site. Residents' food preferences, dietary and cultural requirements are identified at admission and accommodated. Food, fluid, and nutritional needs of residents are provided in line with recognised nutritional guidelines and additional requirements/modified needs were being met.

Safe and appropriate environment

The building holds a current warrant of fitness. All rooms are single with hand basins, and are personalised and spacious. Communal areas are easily accessed and there is adequate room for residents to move freely about the home using mobility aids. Communal areas are well utilised for group and individual activity. The internal areas are able to be ventilated and heated. The outdoor areas are safe, well maintained and accessible.

There is adequate equipment for the safe delivery of care. All equipment is well maintained and on a planned schedule. Electrical equipment is tested and tagged. Chemicals are stored securely throughout the facility. Laundry (provided off-site) services are well monitored through the internal auditing system. The cleaning service maintains a tidy, clean environment. There is an approved evacuation scheme and staff are trained in emergency management procedures. There is water, food and equipment stored for use in an emergency. A first aider is on duty at all times.

Restraint minimisation and safe practice

Restraint minimisation and safe practice policies and procedures are in place. Staff receive training in restraint minimisation and challenging behaviour management. The restraint standards are being implemented and implementation is reviewed through internal audits, facility meetings, and restraint steering group meetings at an organisational level. Interviews with the staff confirm their understanding of restraints and enablers. On the day of audit, the service had four restraints (two bedrails and two lap belts) and no enablers.

Infection prevention and control

The infection control programme and its content and detail are appropriate for the size, complexity and degree of risk associated with the service. The infection control resource nurse (clinical coordinator) is responsible for coordinating/providing education and training for staff. The infection control manual outlines a comprehensive range of policies, standards and guidelines, training and education of staff and scope of the programme. The infection control resource nurse uses the information obtained through surveillance to determine infection control activities, resources and education needs within the facility. This includes audits of the facility, hand hygiene and surveillance of infection control events and infections. The service engages in benchmarking of infections with an external provider. Staff receive ongoing training in infection control.

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 / 48 / 0 / 1 / 0 / 0 / 0
Criteria / 1 / 99 / 0 / 1 / 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 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 / The Health and Disability Commissioner (HDC) Code of Health and Disability Services Consumers' Rights (the Code) poster is displayed in visible locations. Policy relating to the Code is implemented and staff can describe how the Code is incorporated in their everyday delivery of care. Staff receive training about the Code during their induction to the service, which continues through in-service education and training. Interviews with staff (five caregivers, two registered nurses, facility manager, clinical coordinator, activity coordinator, diversional therapist, physiotherapy aide), reflected 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 / There are procedures in place for informed consent and resuscitation and the service is committed to meeting the requirements of the Code of Health and Disability Services Consumers Rights. Policies include informed consent policy, advocacy policy and guidelines for resuscitation.
There were signed general consents including outings and resuscitation status in all seven resident files sampled (three rest home and four hospital level of care residents including one resident under the respite contract and one YPD resident). Resuscitation treatment plans and advance directives were appropriately signed in the files reviewed.
Discussions with staff confirmed that they were familiar with the requirements to obtain informed consent for personal care and entering rooms.
Discussion with relatives confirmed that the service actively involves them in decisions that affect their relative’s lives.
Informed consent processes and family/resident care plan updates are also reviewed through the six-monthly care plan evaluations and multidisciplinary reviews.
Standard 1.1.11: Advocacy And Support
Service providers recognise and facilitate the right of consumers to advocacy/support persons of their choice. / FA / Contact numbers for advocacy services are included in the policy, in the resident information folder and in advocacy pamphlets that are available around the facility. Discussions with residents identified 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 / Residents may have visitors of their choice at any time. The service encourages the residents to maintain relationships with their family, friends and community groups by encouraging their attendance at functions and events, and providing assistance to ensure that they can participate in as much as they can safely and desire to do. Resident meetings are held monthly. The service works with their YPD residents to encourage continued involvement with community groups. The service has a van which is used for outings. Many of the residents have high physical needs, so often it is more appropriate to support family, friends and community groups to come into the facility.