Kiwi Family Otago Limited
Current Status: 24 June 2014
The following summary has been accepted by the Ministry of Health as being an accurate reflection of the Partial Provisional Audit conducted against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008) on the audit date(s) specified.
General overview
Woodhaugh rest home currently provides rest home level care for up to 70 rest home residents. This partial provisional audit was to assess the readiness of the service to provide hospital level care. The audit was completed across three separate site visits.
Woodhaugh has identified annual quality objectives. These include a goal for 2014 around implementing hospital beds. The service is managed by a facility manager (registered nurse) who has managed aged care facilities for a number of years. She is supported by three part time registered nurses.
The organisation completes annual planning and has comprehensive policies/procedures to provide rest home and hospital level care.
Twenty-three resident rooms within the facility have been assessed as suitable for providing hospital level care. A further eight rooms in Gables wing upstairs have been assessed as suitable, subject to a mobility toilet being installed.
The service has addressed shortfalls from the previous audit relating to: pain management, care plan integration, medication documentation, GP reviews of medication charts and review of activity care plans.
This audit identified improvements required around staffing for hospital residents, draft roster, equipment, mobility toilet in Gables wing and stretching carpet in a number of resident rooms.
HealthCERT Aged Residential Care Audit Report (version 4.2)
Introduction
This report records the results of an audit against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008) of an aged residential care service provider. The audit has been conducted by an auditing agency designated under 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).
It is important that auditors restrict their editing to the content controls in the document and do not delete any content controls or any text outside the content controls.
Audit Report
Legal entity name: / Cressida Otago LimitedCertificate name: / Cressida Otago Limited
Designated Auditing Agency: / Health and Disability Auditing New Zealand Limited
Types of audit: / Partial Provisional Audit
Premises audited: / Woodhaugh Rest Home
Services audited: / Hospital services - Geriatric services (excl. psychogeriatric); Rest home care (excluding dementia care)
Dates of audit: / Start date: / 24 June 2014 / End date: / 13 September 2014
Proposed changes to current services (if any):
This partial provisional audit was to review the service's ability to provide hospital level care. The following rooms have been assessed as suitable to accommodate hospital level residents including mobility and transfer equipment and staff. Millhouse wing (eight rooms): The Villa wing: (nine rooms). And Homestead wing (six rooms).
Total beds occupied across all premises included in the audit on the first day of the audit: / 38Audit Team
Lead Auditor / XXXXX / Hours on site / 4 / Hours off site / 3Other Auditors / XXXXX / Total hours on site / 4 / Total hours off site / 1
Technical Experts / Total hours on site / Total hours off site
Consumer Auditors / Total hours on site / Total hours off site
Peer Reviewer / XXXXX / Hours / 1
Sample Totals
Total audit hours on site / 8 / Total audit hours off site / 5 / Total audit hours / 13Number of residents interviewed / 1 / Number of staff interviewed / 3 / Number of managers interviewed / 2
Number of residents’ records reviewed / 5 / Number of staff records reviewed / 5 / Total number of managers (headcount) / 2
Number of medication records reviewed / 10 / Total number of staff (headcount) / Number of relatives interviewed
Number of residents’ records reviewed using tracer methodology / Number of GPs interviewed
Declaration
I, XXXXXX, Director of Christchurch hereby submit this audit report pursuant to section 36 of the Health and Disability Services (Safety) Act 2001 on behalf of Health and Disability Auditing New Zealand Limited, an auditing agency designated under section 32 of the Act.
I confirm that:
a) / I am a delegated authority of Health and Disability Auditing New Zealand Limited / Yesb) / Health and Disability Auditing New Zealand Limited has in place effective arrangements to avoid or manage any conflicts of interest that may arise / Yes
c) / Health and Disability Auditing New Zealand Limited has developed the audit summary in this audit report in consultation with the provider / Yes
d) / this audit report has been approved by the lead auditor named above / Yes
e) / the peer reviewer named above has completed the peer review process in accordance with the DAA Handbook / Yes
f) / if this audit was unannounced, no member of the audit team has disclosed the timing of the audit to the provider / Not Applicable
g) / Health and Disability Auditing New Zealand Limited has provided all the information that is relevant to the audit / Yes
h) / Health and Disability Auditing New Zealand Limited has finished editing the document. / Yes
Dated Monday, 22 September 2014
Executive Summary of Audit
General Overview
Woodhaugh is part of the Cressida Healthcare Ltd group. The service currently provides rest home care for 38 of 70 rest home beds (currently seven respite). This partial provisional audit was to assess the readiness of the service to provide hospital level care.
Woodhaugh identifies annual quality objectives at both service and organisational level, these are implemented at Woodhaugh. Additionally, Woodhaugh has set quality goals for 2014 including implementing hospital beds. The service is managed by a facility manager (registered nurse) who has managed aged care facilities for a number of years. She is supported by three part time registered nurses.
The audit has assessed 23 resident rooms across three wings as appropriate for providing hospital level care. A further eight rooms in Gables wing upstairs have been assessed as suitable, subject to a mobility toilet being installed. The audit was completed across three separate site visits.
The organisation completes annual planning and has comprehensive policies/procedures to provide rest home and hospital level care.
The service has addressed the previous service delivery shortfalls from the previous audit relating to: pain management, integration of allied health professional assessments into the care plan, prescribing of ‘as required’ medication, GP reviews of medication charts and review of activity care plans.
This audit identified improvements required around staffing for hospital residents, draft roster, equipment, mobility toilet in Gables wing and stretching carpet in a number of resident rooms.
Outcome 1.2: Organisational Management
Cressida Group provides a comprehensive orientation and training/support programme for their manager's and all newly appointed staff.
The service has well developed policies and procedures (including clinical procedures) at a service level and organisation plan is structured to provide appropriate safe quality care to people who use the service including residents that require hospital or rest home care.
There are job descriptions available for all relevant positions and staff have individual employment contracts. Duty lists are available for all shifts. Professional qualifications are validated. There are comprehensive human resources policies folder including recruitment, selection, orientation and staff training and development.
Documented competencies are completed as part of orientation. The orientation programme includes specific information for registered nurses. There is an education plan for 2014 that is being implemented. There is an organisational staffing policy that aligns with contractual requirements and includes skill mixes. There is a staffing rationale policy for the Cressida group. The service has a transition plan for recruiting staff for the hospital area; including employment of further registered nurses to ensure there is 24 hour coverage, care and cleaning staff. There is an improvement required to ensure staffing and the draft roster is in place prior to occupancy.
Outcome 1.3: Continuum of Service Delivery
Care planning and documentation has been reviewed since previous audit and improvements have been made in relation to aspects of assessments, care planning, and provision of care and evaluations of care plans. A medication management system is implemented in line with accepted guidelines. There are comprehensive medication management policies. These direct staff in terms of their responsibilities for each stage of medication management. Controlled drugs are stored in a locked safe in a treatment room and advised that only the registered nurses will have access to controlled drugs. Registered nurses will be responsible for medication administration to hospital residents in the facility. The service has an incident/accident form for the reporting of all adverse reactions and medication errors. Meals are prepared on site, there are food service policies and procedures and the menu is reviewed by a registered dietitian. A dietary profile of residents is developed on admission and food preferences are identified. The service has a transition plan relating to the provision of nutrition, safe food and fluid for hospital level residents which includes provision of equipment and specialist diets.
Outcome 1.4: Safe and Appropriate Environment
Woodhaugh provides a safe, secure and appropriate environment for the care of residents requiring rest home care. Chemicals are stored safely and staff are provided with personal protective equipment. The physical environment and fixtures and fittings are maintained, appropriate and safe. There is an improvement required around equipment being in place for hospital residents and stretching the carpet where it has rippled.
The facility has space to enable the use of mobility equipment in the lounge and dining areas that would be utilised for hospital residents. The following rooms have been assessed as large enough to accommodate hospital level residents including mobility and transfer equipment and staff. The Villa, Homestead wing and Millhouse wing have mobility bathrooms and toilets suitable to provide hospital level care. The Gables wing has a mobility bathroom/shower.
Millhouse wing (eight rooms): Rooms – 1e, 3, 4, 5, 6, 13. Also rooms 1 and 1a, (noting these two rooms have limitations due to a narrow hallway and would suit a more mobile resident). The Villa: (nine rooms) Rooms – 91, 97, 99, 100, 102, 102a, 102b, 102c, and 106 have been assessed as suitable to provide hospital level care. Holmstead wing: (six rooms) Rooms- 29, 87, 33a, 33b, 33c, and 33.
Gables wing –upstairs: (eight rooms; subject to a mobility toilet being installed and the call bell system reviewed) Rooms- 55a, 55c, 55e, 55g, 56, 56b, 57, and 58.
There are cleaning and laundry policies and procedures that are monitored and adhere to safety standards. The service has a current building warrant of fitness and an approved fire and evacuation scheme. Furniture and fittings are selected with consideration to residents’ abilities and functioning and rooms are personalised. The service has implemented policies and procedures for civil defence and other emergencies and fire drills are conducted. Staff receive training in first aid and are able to respond to emergency situations. There is a call bell system in all areas. General living areas and resident rooms are appropriately heated and ventilated and have good lighting. There are two large downstairs combined dining and lounge areas which are spacious. Transfers between rooms can be managed in an ambulance stretcher if required.
Outcome 3: Infection Prevention and Control
The infection control (IC) programme and its content and detail, is appropriate for the size, complexity, and degree of risk associated with the service. Infection control and surveillance data is discussed at staff meetings. The infection control coordinator is the registered nurse and she is responsible for Infection control across the facility. In-service has been provided to staff.
Summary of Attainment
CI / FA / PA Negligible / PA Low / PA Moderate / PA High / PA CriticalStandards / 0 / 14 / 0 / 3 / 0 / 0 / 0
Criteria / 0 / 36 / 0 / 3 / 0 / 0 / 0
UA Negligible / UA Low / UA Moderate / UA High / UA Critical / Not Applicable / Pending / Not Audited
Standards / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 33
Criteria / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 62
Corrective Action Requests (CAR) Report
Code / Name / Description / Attainment / Finding / Corrective Action / Timeframe (Days) /HDS(C)S.2008 / Standard 1.2.8: Service Provider Availability / Consumers receive timely, appropriate, and safe service from suitably qualified/skilled and/or experienced service providers. / PA Low
HDS(C)S.2008 / Criterion 1.2.8.1 / There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery. / PA Low / Current staff levels and roster sighted are not adequate to meet the needs of residents requiring hospital level care across the three wings. / Ensure adequate staff are in place including registered nurses across 24/7 and develop a roster to meet the needs of hospital residents across the three wings. / Prior to occupancy
HDS(C)S.2008 / Standard 1.4.2: Facility Specifications / Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for their purpose. / PA Low
HDS(C)S.2008 / Criterion 1.4.2.1 / All buildings, plant, and equipment comply with legislation. / PA Low / A number of resident rooms have loose carpet that required stretching. A plan for purchasing of furniture and equipment has been commenced and requires completion prior to occupancy of hospital residents. / Ensure carpet is stretched in resident areas where the carpet is rippled; ensure equipment is in place for hospital residents / Prior to occupancy
HDS(C)S.2008 / Standard 1.4.3: Toilet, Shower, And Bathing Facilities / Consumers are provided with adequate toilet/shower/bathing facilities. Consumers are assured privacy when attending to personal hygiene requirements or receiving assistance with personal hygiene requirements. / PA Low
HDS(C)S.2008 / Criterion 1.4.3.1 / There are adequate numbers of accessible toilets/showers/bathing facilities conveniently located and in close proximity to each service area to meet the needs of consumers. This excludes any toilets/showers/bathing facilities designated for service providers or visitor use. / PA Low / Eight rooms in Gables wing (upstairs) have been assessed as suitable to provide hospital level care. There is one mobility bathroom/shower, but no mobility toilets. This will need to be addressed if the service provides hospital level care in the upstairs wing. / To provide hospital level care within Gables wing a mobility toilet will need to be available. / Prior to occupancy
Continuous Improvement (CI) Report
Code / Name / Description / Attainment / Finding /NZS 8134.1:2008: Health and Disability Services (Core) Standards
Outcome 1.2: Organisational Management