Home of St Barnabas Trust

Home of St Barnabas Trust

Introduction

This report records the results of a Surveillance 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: Home of St Barnabas Trust

Premises audited: Home of St Barnabas

Services audited: Rest home care (excluding dementia care)

Dates of audit: Start date: 15 December 2014 End date: 16 December 2014

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: 40

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

The Home of St Barnabas is owned and governed by the Anglican Diocese of Dunedin. The home is certified to provide rest home level care for up to 41 residents. On the day of the audit there were 40 residents. The service is managed by an experienced general manager who has been at the service for 18 years (registered nurse). The general manager is supported by deputy manager, a quality coordinator, registered nurses and caregivers. Family and residents interviewed spoke positively overall about the care and support provided.

The service has addressed eight of the ten shortfalls from the previous surveillance audit around collation and analysis of monthly incidents, conducting meetings as per planner, completing education records, maintaining staff records of employment and orientation, aspects of medication management, registered nurses medication competencies, aspects of safe food management and safe food handling training for staff. Further improvements continue to be required around risk assessments and updating care plans when health status changes.

This audit also identified an improvement required around aspects of activity care planning.

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 service has an open disclosure policy stating residents and/or their representatives have a right to full and frank information and open disclosure from service providers. There is a complaints policy and an incident/accident reporting policy. Family members are informed in a timely manner when their family members health status changes. The complaints process and forms for completion were viewed in reception area of the facility. Brochures are also freely available for the Health and Disability and advocacy service with contact details provided. Information on how to make a complaint and the complaints process are included in the admission booklet. 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. / Standards applicable to this service fully attained.

Home of St Barnabas has a current business plan and quality plan to support quality and risk management. Advised that quality information is gathered from internal audits, incidents and accidents, feedback from residents, family and staff. Corrective actions are developed following quality activities to ensure that improvements are followed through. Resident/relative surveys are undertaken annually.

Staff requirements are determined using an organisation service level/skill mix process and documented. The service has a documented training plan. Duty schedules are available for all shifts. Staffing rosters indicate there is suitable staff on duty to care for residents.

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

Care plans are developed with the resident by the registered nurses who also have the responsibility for maintaining and reviewing care plans. Residents and family members interviewed state that they are kept involved and informed about the resident's care.

The medication management system includes medication policy and procedures that follows recognised standards. Caregivers and registered nurses responsible for medication administration have current medication competencies completed.

A range of activities are available and residents provide feedback on the programme. St Barnabas Rest Home has food policies/procedures for food services and menu planning appropriate for this type of service. Residents' food preferences are identified and this includes any particular dietary preferences or needs.

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 that expires 3 March 2015.

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.

There is a restraint minimisation and safe practice policy that includes comprehensive restraint procedures. There is a documented definition of restraint and enablers that aligns with the definition in the standards. The service is restraint free and there are no residents assessed as requiring enablers. There is a restraint register and an enabler’s register.

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 service has addressed the previous certification audit finding around updating the infection control policies. The infection control nurse at the Home of St Barnabas completes a monthly infection summary which is discussed at quality and staff meetings. Infection control education is provided. All infections are recorded on the surveillance monitoring summary. The service effectively managed an outbreak of gastroenteritis in September 2014.

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 / 14 / 0 / 1 / 2 / 0 / 0
Criteria / 0 / 37 / 0 / 1 / 2 / 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 1.1.13: Complaints Management
The right of the consumer to make a complaint is understood, respected, and upheld. / FA / The complaints process and forms for completion are available at the entrance foyer of the facility. Brochures are also freely available for the Health and Disability and advocacy service with contact details provided. A review of complaints received since the last surveillance audit in June 2014 was conducted. A complaints register records the details of all complaints (all written), the date of corrective actions taken and is signed off when resolved. Four complaints were from July –October 2014.
Details of the management of all complaints is recorded including letters of follow up, resident, family and staff meetings and response. Complaints are discussed at the three monthly quality meetings.
One complaint from January 2014 to the DHB is now under review process with the health and Disability Commissioner. The service has responded with all required details and is awaiting an outcome.
D13.3h: A complaints procedure is provided to residents within the information pack at entry.
Standard 1.1.9: Communication
Service providers communicate effectively with consumers and provide an environment conducive to effective communication. / FA / There is an open disclosure policy in place, information on which is included at the time of admission. The policy states residents or their representative have the right to full and open disclosure. Incident and accident forms are completed by either caregivers or a registered nurse and a copy of any incident relating to individual residents is included in the clinical file. A communication sheet records that families are informed following general practitioner (GP) review, incidents or accidents or if there is a change in resident condition (confirmed by one family member interviewed). Notification of next of kin for the incident reports sampled was confirmed through the clinical files reviewed. The service has introduced a new form which details when family wish to be informed. The service is currently implementing this form for each resident. Details of use of the new forms are documented in staff meetings minutes. There is an interpreter policy in place with information included in the admission booklet.
D12.1 Non-Subsidised residents are advised in writing of their eligibility and the process to become a subsidised resident should they wish to do so through the admission booklet. The admission booklet is available in large print and can be read to residents if required. The Ministry of Health “Long-term Residential Care in a Rest Home or Hospital – what you need to know” is provided to residents on entry.
D16.1b.ii: Residents and family are informed prior to entry of the scope of services and any items they have to pay that is not covered by the agreement.
D16.4b: One family member reported being kept informed when their family member’s health status changes.
Standard 1.2.1: Governance
The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers. / FA / Home of St Barnabas rest home is owned by the Anglican Diocese of Dunedin with a trust board providing governance and direction. The facility is managed by an experienced registered nurse who has been in the role for 18 years. The general manager reports monthly to the governing board and chair. Monthly senior management meetings occur with reports tabled relating to activities, kitchen, staffing, occupancy, health and safety, housekeeping. The general manager is supported by the board, a quality coordinator, a kitchen supervisor (deputy manager), registered nurses and care staff. The service has a current business plan which includes a quality and risk management plan for 2014/2015. A quality management system is in place which includes gathering data and information to provide opportunities for quality improvement. The organisation has a philosophy of care which includes the mission statement: “our aim is to promote a friendly, warm, homely environment ensuring individual freedom and security”
ARC, D17.3di: The nurse manager has attended in excess of eight hours of professional development in the past 12 months.
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 / Home of St Barnabas has a current quality and risk management plan for 2014/2015 which includes a quality policy statement, and goals and objectives. Key issues are reported to the monthly senior management meeting. The current objectives include a consumer focus, provision of effective services, certification and contractual requirements, quality and risk management, and continuous improvement.