Sunrise International Funds Limited - Howick Manor

Sunrise International Funds Limited - Howick Manor

Introduction

This report records the results of aSurveillance 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:Sunrise International Funds Limited

Premises audited:Howick Manor

Services audited:Dementia care

Dates of audit:Start date: 1 March 2017End date: 1 March 2017

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:21

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

Sunrise International Funds Limited trading as Howick Manor provides residential dementia services for up to 24 residents and people requiring a dementia level day programme. The higher number of residents has been agreed in writing by the District Health Board. On the day of the audit, there were 21 residents (which included one person receiving respite support services) and one person attending the day programme. A facility manager manages the daily operations and is supported by a full-time registered nurse. The relatives interviewed spoke positively about the care and supports provided at Howick Manor.

This unannounced surveillance audit was conducted against a sub-set of the relevant Health and Disability Standards and the contract with the district health board. The audit process included the review of policies and procedures, the review of residents and staff files, observations and interviews with family, management and staff.

The service has addressed two of two shortfalls from the previous certification audit around the content of the admission agreement, prescribing of ‘as required’ medications and an aspect of medication storage.

The surveillance audit identified that improvements are required in relation to the medicines management system.

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.

Accidents, incidents and complaints alert staff to their responsibility to notify family/next of kin of any event that occurs and family state that they are fully informed at all times. Three monthly family meetings provide a forum to discuss any issues or concerns. The complaints procedure is provided to residents and relatives as part of the admission process. There have been no complaints made since the last audit.

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.

Howick Manor has an implemented quality and risk management system. Key aspects of the quality improvement and risk management programme include monitoring of incidents and accidents, health and safety, implementation of an internal audit schedule and surveillance of infections. There is an annual family satisfaction survey. The service has policies and procedures that are reviewed by an external consultant. The service has human resources procedures for staff recruitment and employment. There is an implemented orientation programme and an implemented annual training schedule in place. Staffing levels safely meet the needs of the residents and all caregiving staff have either completed the dementia training or if newly appointed, are enrolled in the programme.

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.

Residents are screened and approved prior to entry to the service. There is a comprehensive admission package available prior to, or on entry to the service, that includes information on the behaviour management policy. The registered nurse is responsible for each stage of service provision. The registered nurse assesses and reviews residents' needs, outcomes and goals with the resident (as appropriate) and/or family/whānau input and completes interRAI assessments. Resident files included medical notes by the contracted GP and visiting allied health professionals.

The diversional therapist provides an activities programme for the residents that is varied, interesting and involves the families/whānau and community. Residents have an individualised 24-hour activity plan developed on admission.

Medication policies are in place. Care staff responsible for administration of medicines complete education and medication competencies.

Meals are prepared on site by the cook and individual and special dietary needs are catered for. Nutritional snacks are available 24 hours a day for the residents. Family interviewed responded favourably to the food that is provided.

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 building has a current warrant of fitness. There have been no building alterations since the previous audit.

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.

Restraint policy and procedures are in place. The definitions of restraints and enablers are congruent with the definition in the restraint minimisation standard. Environmental restraint is in place for all residents. Enablers are not used as residents are not able to agree to their use. The service has no resident using any other form of restraint.

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 programme includes the surveillance programme. The programme is overseen by the infection prevention and control coordinator who is the registered nurse. Surveillance data are collected, recorded and analysed. There have been no outbreaks of infection in the period 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 / 0 / 16 / 0 / 0 / 1 / 0 / 0
Criteria / 0 / 41 / 0 / 0 / 1 / 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 1.1.13: Complaints Management
The right of the consumer to make a complaint is understood, respected, and upheld. / FA / The service has a complaints policy that describes how complaints are managed and is in line with requirements set by the Health and Disability Commissioner (HDC). Complaints forms and a locked suggestions box is located at the entrance to the facility. Information about complaints is provided on admission. Family members interviewed confirmed their understanding of the complaints process. Three care staff interviewed were able to describe the process around reporting complaints. There have been no complaints made since the last audit.
Standard 1.1.9: Communication
Service providers communicate effectively with consumers and provide an environment conducive to effective communication. / FA / There is a policy to guide staff on the process around open disclosure. Twelve accident/incident forms for January and February 2017 were reviewed with evidence of open disclosure documented. Interviews with the facility duty manager and registered nurse (RN) confirmed family are notified following changes in health status. Three family members interviewed stated they were kept informed of any health changes including accidents/incidents, infections and general practitioner (GP) visits. Three monthly family meetings provide a forum to discuss issues or concerns on every aspect of the service. The service provides information and support for families around dementia care.
Standard 1.2.1: Governance
The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers. / FA / Howick Manor provides care for up to 24 dementia level of care residents. On the day of audit there were 21 residents (including one resident on respite). Howick Manor is one of three aged care facilities owned by two directors.
The service has an agreement to provide aged residential care for Counties Manukau District Health Board. It is able to provide carer support on an individual basis. It has a discretionary arrangement with the Needs Assessment and Support Coordination agency to provide a day services programme to a small number of people on an individual basis.
There is a 2016–2018 business plan in place that reflects the family centred approach to care, it has been reviewed annually. The plan outlines objectives for the period that includes: increasing occupancy rates to 96%, staff education, ongoing maintenance plan and utilisation of the outdoor areas for activities. A five year development plan includes: refurbishment of the main office, new indoor/outdoor furnishings, development of outdoor areas and upgrade of administration system.
A facility duty manager (non-clinical) reports to the directors and is supported by a full-time RN. The full-time facility duty manager has been in position for 14 years. The facility duty manager lives on the premises and is supported by a qualified diversional therapist who is responsible for oversight of the activities programme. The RN has been in the role for one year and has several years work experience at another aged care facility.
The facility duty manager and both directors have maintained at least eight hours annually, of professional development activities related to managing an aged care facility. The RN has also maintained at least eight hours annually of professional development activities related to her clinical role.
Standard 1.2.3: Quality And Risk Management Systems
The organisation has an established, documented, and maintained quality and risk management system that reflects continuous quality improvement principles. / FA / A quality and risk management system is in place. There are policies and procedures being implemented to provide assurance that the service is meeting accepted good practice and adhering to relevant standards, including those standards relating to the Health and Disability Services (Safety) Act 2001. The content of policy and procedures are detailed to allow effective implementation by staff.
Quality data and outcomes are taken to the bi-monthly integrated committee meetings and then to the bi-monthly staff meetings, that all staff are invited to attend. Meeting minutes demonstrate key components of the quality management system, including: internal audit, infection prevention and control, incidents (and trends) and in-service education. The service has linked the complaints process with its quality management system and communicates relevant information to staff. Meeting minutes reviewed indicate issues raised are followed through and closed out, including three monthly family meetings. Issues arising from internal audits are reported on the audits action sheet and were sighted to have been closed out.
There were four responses to the annual relative survey completed in July 2016. The facility duty manager contacted families (due to low response rate) to identify any areas for improvement or dissatisfaction. There is a health and safety and risk management programme in place including policies to guide practice. The duty manager/diversional therapist is the health and safety coordinator. Staff accidents/incidents and identified hazards are monitored.
Falls prevention strategies are in place that includes the analysis of falls incidents and the identification of interventions on a case-by-case basis to minimise future falls. The service has lifting belts, hip protectors and access to sensor mats if necessary.
Standard 1.2.4: Adverse Event Reporting
All adverse, unplanned, or untoward events are systematically recorded by the service and reported to affected consumers and where appropriate their family/whānau of choice in an open manner. / FA / The service collects incident and accident data and reports aggregated figures bi-monthly to the integrated committee meeting and staff meeting. Incident forms are completed by staff that either witnessed an adverse event, or were the first to respond. The resident is reviewed by the RN on duty at the time of the event or is notified by caregivers of incidents after hours. Twelve incident forms were reviewed and all were completed appropriately. Discussions with the facility duty manager confirmed her awareness of the requirement to notify relevant authorities in relation to essential notifications. There have been no notifications of events to external agencies.
Standard 1.2.7: Human Resource Management
Human resource management processes are conducted in accordance with good employment practice and meet the requirements of legislation. / FA / There are human resources policies to support recruitment practices. The RN has a current practising certificate. The RN completes interRAI assessments. Five staff files (one duty manager, one RN, one activities coordinator and two caregivers) reviewed had relevant documentation relating to employment. Annual performance appraisals were completed. The service has an orientation programme in place that provides new staff with relevant information for safe work practices. The orientation programme includes documented competencies and induction checklists. Staff interviewed were able to describe the orientation process and reported new staff were adequately orientated to the service.