Metlifecare Limited - Palmerston North

Metlifecare Limited - Palmerston North

Introduction

This report records the results of a Certification 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 byThe DAA Group 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:Metlifecare Limited

Premises audited:Metlifecare Palmerston North

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

Dates of audit:Start date: 6 May 2015End date: 7 May 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:37

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

Palmerston North Village is a 50-50 joint venture entity between Metlifecare Limited and Palmerston North Maori Reserve Trust. There is a Board of Trustees which includes three members from each entity. Metlifecare Limited is responsible for all operational tasks. The facility is one of 23 operated by the Metlifecare Limited group and the Palmerston North facility provides rest home and hospital level care for up to 38 residents.

This certification audit was conducted against the Health and Disability Services Standards and the provider’s contract with the district health board. The audit process included the review of policies and procedures, the review of staff files, observations, and interviews with residents, family/whānau, management, staff and a general practitioner.

Improvements have been made to address areas previously identified for improvement with the exception of corrective action follow up relating to incident and accident review. This is included in the six areas identified for improvement at this audit. These are incident and accident reporting documentation, ensuring all resident information is not publicly accessible, consistency of care planning information, completion of evaluations to indicate the outcome, medication administration and the frequency of call bell checks.

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.

During the audit, residents were observed being treated in a professional manner. Staff receive regular and ongoing training on the rights of residents and how these should be implemented. Services are provided that respect the independence, personal privacy, individual needs and dignity of residents.

Policies are in place to guide staff in ensuring residents are free from discrimination or abuse/neglect. Staff are familiar with these policies and their implementation in practice. The services provided to residents are of an appropriate standard. Residents and their families reported their satisfaction with the services and the open communication with staff.

The service implements policy and procedures to ensure all complaints are documented, reviewed, followed up and fully addressed. At the time of audit there are no open complaints.

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. / Some standards applicable to this service partially attained and of low risk.

The board of trustees (the board) consists of three members from each group. The village manager reports monthly to the board on all topics related to the provision of service. Metlifecare are responsible for all operational activities.

Metlifecare Limited’s governing body ensure that business and strategic planning are in place, covering all aspects of service delivery, to show how services are planned and coordinated to meet community needs. Strategic planning occurs annually. Management review and report to the Board, against set goals, quarterly.

The nurse manager, who is a registered nurse, is responsible for the care facility service delivery, with the village manager being responsible for the overall site.

The service has well established quality and risk management systems which are understood by staff. Quality management reviews include an internal audit process, complaints management, resident and family/whānau satisfaction surveys, restraint, incidents/accidents and infection control data collection. Quality and risk management activities and results are shared among staff, management and residents, as appropriate. All deficits found are managed using a well-documented corrective action process. Incident and accident forms are not always completed to meet policy requirements. This is an area identified for improvement.

Staff who work in the care unit are appropriately experienced, educated and qualified. As confirmed during resident and family/whānau interviews and in the 2014 satisfaction survey results, residents’ needs are met.

The service implements the documented staffing levels and skill mix to ensure contractual requirements are met. Human resources management processes implemented identify good practice and meet legislative requirements.

Ensuring that residents’ private information is maintained in a secure manner is an area requiring improvement.

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.

An established care planning processes is in place to guide care delivery. Care plans are individualised, based on a comprehensive and integrated range of clinical information and include input from residents and families. The evaluation of short term care plans, the updating of care plans when resident’s needs change, and ensuring consistency between identified care needs, goals and interventions are areas for improvement.

Registered nurses are on duty 24 hours each day, with either the nurse manager or the senior registered nurse available on call after hours. Residents’ progress notes are updated each shift and there are well-developed processes in place, such as verbal handovers and communication sheets, to guide continuity of care.

The kitchen was well organised and maintained in a clean and hygienic manner. Staff have the appropriate food safety qualifications and all aspects of food services were well managed. The individual food preferences and dietary needs of residents are respected and accommodated. There are two separate dining areas for residents.

An experienced, fulltime diversional therapist manages the activity programme, which offers residents a variety of individual and group activities. Residents are encouraged to maintain their links with the community and a facility van is available to take residents on outings or attend activities in the community.

Medications are administered by registered nurses and senior caregivers, all of whom have been assessed as competent in relation to medicines management. Medications are prescribed in accordance with legislative and safe practice requirements. The management of medications is safe and appropriate, with the exception of administering medications within the prescribed timeframes (vitamin injections only) which is an area for improvement.

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. / Some standards applicable to this service partially attained and of low risk.

There are documented emergency management response processes which are understood and implemented by the service providers. This includes protecting residents, visitors and staff from harm as a result of exposure to waste or infectious substances.

The building has a current building warrant of fitness and the service has an approved fire evacuation plan. Medical and electrical equipment is checked at least annually by an approved provider. Residents’ call bells are not being checked six monthly as required in policy and this needs to be addressed.

The facilities meet residents’ needs with the provision of appropriate furnishings, single bedrooms, adequate toilet, bathing, hand washing, dining and relaxation areas.

The facility is appropriately heated and ventilated. The outdoor areas provide suitable furnishings and shade for residents’ use.

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 approval and assessment processes are in place and known to staff. Staff undertake annual education related to restraint minimisation and they have a clear understanding of the difference between enablers and restraint. Restraint is put in place for safety reasons only.

At the time of audit there were nine residents using restraints and four enablers in use. All restraints have been evaluated three monthly to ensure continued use of restraint is required. The restraint register clearly documents each restraint event and when it is next due to be evaluated. Resident and family/whānau input into approval and ongoing reviews are documented.

Internal quality reviews of the entire restraint process are undertaken every six months, the most recent being April 2015 following some quality improvements that were put in place. A 95% compliance rate was achieved. This process is very clearly documented.

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 is well managed by the service. Staff undergo regular training related to infection control, and have easy access to an appropriate range of personal protective equipment. The infection control coordinator has received relevant training, and is supported in that role by the nurse manager and the infection control committee.

Evidence was sighted of a systematic approach to infection surveillance. The results of the surveillance programme are reported monthly, with data being benchmarked both internally and also externally with other Metlifecare facilities.

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 / 44 / 0 / 4 / 2 / 0 / 0
Criteria / 0 / 95 / 0 / 4 / 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, areretained 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 / Education related to the Health and Disability Commissioner’s Code of Health and Disability Services Consumer’s Rights (the Code) is included in staff orientation, as confirmed by the nurse manager. Two-yearly education on the Code is also provided for staff, as reviewed in staff education records. When interviewed staff demonstrated a clear understanding of the Code and were able to explain how this would be incorporated into their everyday practice.
The service regularly audits compliance with residents’ rights. The last audit was undertaken in November 2014. A review of survey results revealed 98% compliance with the service’s strategies to ensure resident rights are maintained.
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 / Residents and/or families are initially provided with information related to informed consent in the admission agreement, which must be signed as part of the admission process. This includes consent in relation to transportation, the taking of photographs, and the collection of information. Consent for additional medical/surgical treatment, such as a flu vaccination, is obtained on an as-required basis. Flu vaccinations were currently being organised for residents, and the relevant consent forms were sighted.
Residents and families interviewed confirmed they were consistently given the opportunity to make informed choices and that their consent was obtained and respected. Family members reported they were kept informed in a timely manner about any changes to the resident’s condition and were consulted in situations such as when consideration was being given to transferring the resident to a public hospital.
The admission documentation completed by each new resident and/or their family member identified inclusions and exclusions in service. The nurse manager advised that head office maintains a database to ensure that signed admission agreements are held for every resident.
The advance directives form includes information related to resuscitation status. All forms sighted had been completed by either the resident themselves, or their doctor if the resident was deemed not competent to make such a decision. The senior registered nurse advised these directives were reviewed three-monthly.
Standard 1.1.11: Advocacy And Support
Service providers recognise and facilitate the right of consumers to advocacy/support persons of their choice. / FA / Information on the Advocacy Service is included in the staff orientation programme and in the ongoing education programme for staff. This was confirmed in staff orientation and training records. As part of the admission process all residents are given a copy of the Nationwide Health and Disability Advocacy Service (Advocacy Service) brochure. Additional copies of this brochure were also available at reception. On interview, residents/families and staff demonstrated their understanding of the Advocacy Service, including how to contact this 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 / The service has unrestricted visiting hours and visitors are encouraged. All family members interviewed stated they felt very welcome when they came to visit and that they felt staff were also interested in their wellbeing.
Outings are organised that enable residents to participate in community events while community groups and entertainers visit the facility regularly. For example, the diversional therapist reported that the facility van and a mobility taxi are used to take residents to a weekly friendship club in Palmerston North.