The Hillview Trust Incorporated - Hillview Home and Hospital

The Hillview Trust Incorporated - Hillview Home and Hospital

Introduction

This report records the results of aCertification 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 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:The Hillview Trust Incorporated

Premises audited:Hillview Home and Hospital

Services audited:Hospital services - Geriatric services (excl. psychogeriatric); Rest home care (excluding dementia care)

Dates of audit:Start date: 16 May 2016End date: 17 May 2016

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:45

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

Hillview Home and Hospital is owned and operated by a charitable trust. The service provides rest home and hospital level of care for up to 52 residents. At the time of audit there were 45 residents.

A full certification audit was conducted against the Health and Disability Services Standards and the service’s contract with the district health board. The audit process included the onsite audit and the review of documentation, observations and interviews. This audit report is an evaluation of the combined evidence on how the service meets each of the standards.

There are three required improvements identified at this audit. These are related to care planning, short term care plan interventions and evaluations, and medicine management.

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.

Staff demonstrate knowledge and understanding of the Health and Disability Commissioner's Code of Health and Disability Services Consumers' Rights (the Code of Rights). Residents and their families are informed of their rights at admission and throughout their stay. Available throughout the facility are copies of the Code of Rights posters and information relating to the Nationwide Health and Disability Advocacy Service.

Residents and families receive clinical services that have regard for their dignity, privacy and independence. The residents' ethnic, cultural and spiritual values are assessed at admission to ensure they receive services that respect their individual values and beliefs.

Evidence-based practice is supported and encouraged to ensure residents receive services of an appropriate standard. Residents have access to visitors of their choice and are supported to access community services.

The service has an easy to use complaints management system. There is a complaints register that contains any complaint received and actions taken to address any shortfalls.

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.

The service is managed to meet the needs of the residents at rest home and hospital level of care. Organisational structures and processes are monitored at the management/operations and board levels. Service performance is aligned with the strategic business plan. There is a robust documented and implemented quality and risk management system that supports the provision of clinical care and support. Review of service delivery includes incidents/accidents, infections, complaints and reports from the internal audit programme.

The general manager and clinical manager are both suitably qualified and experienced to manage the service. The general manager reports to the Board of Trustees.

Policies are reviewed by the management team two yearly and reflect current accepted best practice.

The adverse event reporting system is planned and coordinated with staff documenting and reporting adverse, unplanned or untoward events.

Systems for human resources management are established. There are adequate staff numbers each shift to meet the resident’s needs at the various levels of care. The education programme for all staff is available and planned for the year. Staff education is encouraged. The education, training and orientation processes for staff have undergone extensive review, are linked to the organisation’s strategic directions and are achieving improved outcomes 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.

Residents receive appropriate services that meet their desired goals/outcomes. Residents are admitted with the use of standardised risk assessment tools. Care plans are not consistently developed and evaluated for all residents. Short term care plans are insufficiently detailed.

Planned activities are appropriate to the needs, age and culture of the residents. Residents reported that activities are enjoyable and meaningful to them.

The medicine management system does not consistently meet the required regulations and guidelines. Improvement is required in relation to “as required” medications and telephone orders.

Food services meet the individual food, fluids and nutritional needs of the residents.

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.

All building and plant complies with legislation with a current building warrant of fitness displayed. Ongoing maintenance ensures the building is maintained to meet the needs of the residents. Fixtures, fittings, floor and wall surfaces are made of acceptable materials for this environment. There are adequate numbers of toilets, showers, and bathing facilities located throughout the facility that provide adequate privacy.

The environment is appropriate for rest home and hospital level of care services. All areas ensure physical privacy is maintained and have adequate space and amenities to facilitate independence.

There are processes in place to protect residents, visitors, and staff from exposure to waste and infectious or hazardous substances, and to provide safe and hygienic cleaning and laundry services.

The facility has an appropriate call system installed. There is access to external gardens, grounds and courtyards for residents and their visitors. The physical environment minimises risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the residents.

Routine safety checks and internal audits are performed by maintenance personal and management. Emergency preparedness was evident with adequate resources being available in the event of an emergency. Staff are trained appropriately in all aspects of health and safety in the work place.

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.

The service has clear and comprehensive policies and procedures which meet the requirements of the restraint minimisation and safe practice standard. There are established systems and practices. Risk management plans are in place. Staff training occurs at least annually. Monitoring and review of individual restraint interventions occurs at an appropriate frequency. The restraint register is current.

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.

Infection prevention and control policies and procedures are clearly documented and implemented to minimise risk of infection to residents, staff and visitors. The type of surveillance is appropriate to the size and complexity of the service. Infection rate data is collected, recorded, analysed and reported. Recommendations to reduce infection rates are discussed. The infection control coordinators are responsible for implementing and evaluating the infection prevention and control programme.

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 / 47 / 0 / 2 / 1 / 0 / 0
Criteria / 0 / 98 / 0 / 2 / 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 1.1.1: Consumer Rights During Service Delivery
Consumers receive services in accordance with consumer rights legislation. / FA / Staff interviewed demonstrated their knowledge of the Code of Health and Disability Services Consumers' Rights (the Code). The Code is included in staff orientation and in the annual in-service education programme. Residents' rights are upheld by staff (e.g., staff knocking on residents' doors prior to entering their rooms, staff speaking to residents with respect and dignity, staff calling residents by their preferred names). Staff observed on the days of the audit demonstrated knowledge of the Code when interacting with residents.
The residents reported that they are treated with respect and understand their rights. The relatives reported that residents are treated with respect and dignity.
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 / Evidence is seen of the consent process for the collection and storage of health information, outings and indemnity, use of photographs for identification, sharing of information with an identified next of kin, and for general care and treatment. The resident’s right to withdraw consent and change their mind is noted. Information is provided on enduring power of attorney (EPOA) and ensuring, where applicable, this is activated.
There are guidelines in the policy for advance directives which meet legislative requirements. An advance directive enables a resident to choose if they would like active medical treatment to prolong life, transfer to base hospital for on-going treatment or receive ‘comfort care’. The files reviewed have signed advance directive forms which meet legislative requirements
Family members and residents are actively involved and included in care decisions as evidenced in residents' files reviewed.
Standard 1.1.11: Advocacy And Support
Service providers recognise and facilitate the right of consumers to advocacy/support persons of their choice. / FA / Advocacy information is available in brochure format at the entrance to the facility. Residents and their families are aware of their right to have support people. Education from the Nationwide Health and Disability Advocacy Service is undertaken annually as part of the in-service education programme. The staff report knowledge of residents’ rights and advocacy service. A number of referrals to advocacy services were sighted.
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 / The residents report they have access to visitors of their choice. Residents reported they are supported to be able to remain in contact with the community through outings and visits from community organisations to the service.
Standard 1.1.13: Complaints Management
The right of the consumer to make a complaint is understood, respected, and upheld. / FA / The complaints register and sample of complaints for 2015 and 2016 evidences that complaints are managed within time frames of Right 10 of the Code. Complaints forms are available at the entrance, with information given on the complaints process as part of the admission procedure and advocacy session with residents and families. Residents and family/whanau report they are encouraged to provide feedback or make a complaint.
The service has had an external complaint that has been finalised since the last audit. This has been closed and no further action is required.
Standard 1.1.2: Consumer Rights During Service Delivery
Consumers are informed of their rights. / FA / Policy detailed that staff will be provided with training on the Code and that residents will be provided with the Code information on entry to the service. Opportunities for discussion and clarification relating to the Code are provided to residents and their families. Discussions relating to residents' rights and responsibilities take place formally (in staff meetings and training forums) and informally (eg, with the resident in their room). Education is held annually. Residents are addressed in a respectful manner and by their preferred names as was confirmed in interview with residents.
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 / All rooms are single occupancy. The privacy and dignity policy details how staff are to ensure the physical and auditory privacy of residents, ensuring the protection of personal property and maintaining the confidentiality of residents’ related information. The process for accessing personal health information is detailed. Staff report knowledge of residents' rights and understand dignity and respect.