Morningview Health Care Limited - Morningview Village Rest Home

MorningView Health Care Limited - Morningview Village Rest Home

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 Audit (NZ) 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:MorningView Health Care Limited

Premises audited:

Services audited:Dementia care

Dates of audit:Start date: 14 July 2015End date: 15 July 2015

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: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.

General overview of the audit

Morningview Village Rest Home provides rest home and dementia level care services for up to 42 residents. On the day of the audit there were five residents residing in the dementia area and twenty two residents receiving rest home level care.

The audit was commissioned by the potential owners. The purpose of this audit was to assess the organisations level of conformity against current requirements, and to assess the preparedness of the prospective owners. The prospective owners are not planning to change any of the services, the facility or the current capacity.

A number of improvements had been made since the previous audit; however there are a number of areas which still require further action. This audit identified an additional 18 areas requiring improvement.

Consumer rights

Information about resident rights, including the complaints process, is available to residents. Staff attend training on all aspects of resident rights. The prospective owners are aware of the requirements of the Code of Health and Disability Services Consumers’ Rights (the Code). Satisfaction surveys are offered to residents. The complaints process meets the requirements of the Code. Family members stated that they are welcome to visit the facility and are encouraged to contribute to the planning of care for the residents. Residents stated that they are encouraged to maintain as much independence as possible and that staff are respectful of their rights. Previous areas requiring improvement have been addressed, except for informed consent. Two additional areas requiring improvement have been identified. These include cultural procedures and meeting good practice requirements.

Organisational management

The prospective owners will become the directors and intend to continue with the current business plan and business continuity and risk management plan. There is a planned lead in time and handover from the current owners. There is a suitably qualified facility manager in place; however a person to fulfil this role during a temporary absence is still required. There have been some improvements made to the quality and risk management system since the previous audits; however a number of improvements are still required. The prospective owners intend to continue with the current system. This includes maintaining, and implementing current policies and procedures. Incidents and accidents are documented and remedial actions implemented as required. The prospective owners intend to maintain current staffing. Staffing levels meet requirements. A previous improvement regarding staff training in dementia has been addressed. Resident records are documented as required. An improvement is required to ensure the security of electronic records.

Continuum of service delivery

The prospective owners are aware of resident requirements and intend to work with staff to provide suitable care. There are processes in place to assess and plan the care needs of the residents within contractual time frames. Staff are trained and qualified to perform their roles and deliver all aspects of service provision. The clinical manager provides oversight of the care and management of all residents. The residents’ care plans identify needs, outcomes and/or goals. Short term care plans are developed for acute conditions. Continuity of care is maintained. Activities are provided in both the rest home and the dementia unit. Medicine management policies and procedures are documented and residents receive medicines in a timely manner. All food is prepared on site. Menus are suitable for the needs of the older person. Previous improvements on short term care planning, assessment, medicine transcribing and oversight of the activities’ staff have been addressed. Five areas requiring improvements have been identified. These include the completion of current activity plans, evaluation of long term care plans, medicine management, staff medicine competency and food safety. The requirement regarding medication competencies is allocated a high risk.

Safe and appropriate environment

The prospective owners intend to continue the current maintenance programme for the facility. Morningview Village Rest Home is located in three attached lodges, each joined internally by a sloped corridor at a gradient suited to the residents. Lodge three was not used by residents at the time of the audit. A separate house on the same site is used to provide care for residents with dementia. The facility is comfortable and homelike throughout. The building warrant of fitness is current. Supplies are available in the event of an emergency. Previous improvements on emergency management have been addressed, except for the location of the approved evacuation plan which remains an area requiring improvement. An additional four areas requiring improvements have been identified. These include equipment safety, safe locking mechanisms, hot water monitoring and the temperature of resident’s bedrooms.

Restraint minimisation and safe practice

Morningview Village Rest Home actively promotes restraint minimisation and safe practice. The restraint minimisation programme defines the use of restraints and enablers by the service. The restraint register is current. Risk assessment, documentation, monitoring, maintaining care, and reviews are outlined in the current policies and procedures. These policies and procedures comply with the standard for restraint minimisation and safe practice. There were no residents using restraint or enabler on audit days. The staff demonstrate good knowledge on restraint minimisation and the use of enablers. The previous area of restraint accountability requiring improvement has been addressed.

Infection prevention and control

Morningview Village Rest Home’s infection control programme is reviewed annually for its continuing effectiveness and appropriateness for the facility. Staff education in infection prevention and control is conducted as per the education calendar. Infections are investigated and appropriate antibiotics are prescribed. The surveillance data is collected monthly and appropriate interventions put in place to reduce infections. There are adequate sanitary gels and hand washing facilities for staff, visitors and residents. Staff are able to explain how to break the chain of infection.

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
Standards applicable to this service 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 / 31 / 1 / 10 / 3 / 1 / 0
Criteria / 0 / 76 / 0 / 14 / 3 / 1 / 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 Code of Health and Disability Services Consumers’ Rights (the Code) is addressed during staff orientation. Staff attended training on the Code in May 2015. In interviews, staff were familiar with the requirements of the Code and gave examples of how this is applied in their work.
In interview, the prospective owners were well versed in their requirements under 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. / PA Low / Informed consent is addressed in the resident welcome pack and includes the involvement of family in the planning of care for the resident. Information about the use of advance directives is available. Service agreements and the informed consent forms are signed by the resident if able and considered competent. The delegated enduring power of attorney (EPOA) signs consents and directives for residents considered not competent. Evidence of EPOA’s was not consistently sighted and an improvement is required.
There is a process to indicate the resuscitation status of the resident. The previous area requiring improvement (identified October 2014 and March 2015) relating to the signing of service agreements has been addressed.
Standard 1.1.11: Advocacy And Support
Service providers recognise and facilitate the right of consumers to advocacy/support persons of their choice. / FA / Health advocacy service pamphlets are displayed at the facility. The facility manager knows the local health advocate and invites the advocate to visit residents to discuss the service. The resident’s welcome pack records that family/whanau are welcome to participate in the care of the resident. Communication with the family is recorded on the family contact sheet, in progress notes and incident and accident reporting forms. Interview with relatives verified that they can be involved in the planning of care for the resident and know how to access the advocacy service.
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 / Visitors and members of the Royal New Zealand Society for the Prevention of Cruelty to Animals (SPCA) and their dogs were observed visiting residents during the audit. Some residents attend church services outside the facility and are taken on outings with family members. The activities programme includes outings to a local café. Interview with residents verified that friends and family and entertainers visit the facility as part of the activities programme.
Standard 1.1.13: Complaints Management
The right of the consumer to make a complaint is understood, respected, and upheld. / FA / Information about the complaints process is addressed in the resident’s welcome pack and complaints forms are displayed. The concerns/complaints policy includes the requirements of Right 10 of the Code. Staff attend training on complaints management. The facility manager is the complaints officer. A clear explanation of the complaints procedure was provided by the facility manager.
A hard copy complaints register is available to record all complaints, dates and actions taken. No complaints had been recorded. No complaints were being investigated by the health and disability commission.
In interview, residents and family members were aware of the complaints process.
Standard 1.1.2: Consumer Rights During Service Delivery
Consumers are informed of their rights. / FA / Information about resident rights and the health advocate is addressed in the facility’s welcome book. Pamphlets and posters describing the Code and pamphlets describing the health advocacy service are displayed in resident areas. Satisfaction surveys and interviews with residents verified that residents’ rights are observed.
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 / There is sufficient space for the storage of personal possessions in residents’ rooms. Security of personal possessions and the use of CCTV cameras are addressed in the resident’s welcome pack. Money or other valuables can be securely stored in the facility manager’s office. Notices inform residents and visitors that CCTV cameras are in operation for the safety of residents. Staff were observed knocking before entering residents’ rooms.
At the time of the audit two married couples were using larger rooms in the rest home. There was adequate space for both residents. All other residents have single rooms.
Cultural and spiritual beliefs are recorded on the resident’s risk and admission assessment and in care plans. Some residents attend church services outside the facility. Independence and mobility is encouraged. Participation in activities is encouraged and was observed.
Policies address resident safety and abuse prevention. There were no reported incidents of abuse.
Interview with residents and relatives verified that the independence of the resident is encouraged and resident privacy is respected. Staff attended training on abuse and neglect in March 2015. Interview with staff verified that they encourage resident independence and are aware of privacy requirements.
Standard 1.1.4: Recognition Of Māori Values And Beliefs
Consumers who identify as Māori have their health and disability needs met in a manner that respects and acknowledges their individual and cultural, values and beliefs. / PA Negligible / Individual and cultural, values and beliefs are recorded on the resident’s risk and admission assessment and in care plans. Morningview Village Rest Home employs two Maori healthcare assistants (HCA). Relatives are involved in planning of care for residents. The facility manager is familiar with tikanga and can access kaumatua, if required.
Staff attended training on cultural sensitivity and the Treaty of Waitangi. Interview with one Maori resident verified that the care provided was culturally respectful and relatives visited.
Policies and procedures on cultural considerations have not been developed and an improvement is required.
Standard 1.1.6: Recognition And Respect Of The Individual's Culture, Values, And Beliefs
Consumers receive culturally safe services which recognise and respect their ethnic, cultural, spiritual values, and beliefs. / FA / Cultural support options and the recognition of values and beliefs are addressed in the resident welcome pack. Interview with staff verified that they have access to care plans and are informed about the residents’ spiritual and cultural requirements. Interview with relatives verified that they are consulted about the cultural and spiritual beliefs of the resident if the resident was unable to explain these.
Standard 1.1.7: Discrimination
Consumers are free from any discrimination, coercion, harassment, sexual, financial, or other exploitation. / FA / Morningview Village Rest Home has a complaints process, a code of conduct and a disciplinary process. Each role has a job description that describes accountabilities, duties and responsibilities and all staff signed an individual employment agreement. The policy on residents’ safety and abuse prevention and security describes procedures for the prevention and management of abuse and neglect. Interview with staff verified that staff were aware of professional boundaries and had not sighted or reported any resident abuse or neglect.
Residents interviewed confirmed that they felt safe.
Standard 1.1.8: Good Practice
Consumers receive services of an appropriate standard. / PA Moderate / The organisation provides a training programme based on the care of the older person. There is evidence that policies and procedures are constantly being improved and better implemented. All residents have access to the required clinical and nursing care. In interview, the GP made reference to the competence of the nursing team.