Waverley Aged Care Limited

Waverley Aged Care Limited

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:Waverley Aged Care Limited

Premises audited:Waverley House Rest Home

Services audited:Rest home care (excluding dementia care)

Dates of audit:Start date: 12 February 2015End date: 12 February 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:19

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

Waverley House is certified to provide rest home level for up to 20 residents. On the day of the audit there were 19 residents. The rest home has been operated by a husband/wife team for ten years. They are supported by a registered nurse.

This unannounced surveillance audit was conducted against a sub-set of the relevant Health and Disability Standards and the contract with the District Health Board. This audit process included the review of policies and procedures, the review of residents and staff files, observations, and interviews with residents, family, management and staff

The service has addressed seven of the eight shortfalls from their previous surveillance audit around policy reviews, internal audits, surveys and results, performance appraisals, initial assessments, evaluations, medication documentation and medication competencies. Further improvements continue to be required around dietitian review of the menu.

This audit also identified improvements around currency of policy content, family notification post incidents, audit corrective actions, restraint documentation, care interventions, fridge and freezer temperatures and functional check of the hoist.

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

Waverley House practices in accordance with the Health and Disability Commissioner (HDC) Code of Health and Disability Services Consumers' Rights "the Code" and copies of the code are displayed in the main entrance. There is a complaints policy supporting practice. There have been no complaints since the previous audit. There is an improvement required around family notification following accidents/incidents.

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 2014 business plan is under review with goal setting in progress for 2015. The service has reviewed its policies and procedures. The internal surveys have been collated and communicated to participants. Quality, health and safety and infection control are set agenda items at the quality/staff meetings. Staff interviewed confirmed they are kept informed on risk management matters. There is an internal audit programme in place. Accidents/incidents are collated monthly and results are available to staff.

Newly employed staff have completed an orientation programme. The education planner covers compulsory training requirements for aged care.

There are improvements required around audit policy content to meet current best practice and internal audit corrective actions.

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.

The residents' needs, interventions, outcomes/goals have been identified and these were reviewed on a regular basis with the resident and/or family/whanau input. Care plans demonstrate service integration. Care plans are reviewed six monthly, or when there are changes in health status. There is an improvement required around care interventions. Resident files include notes by the GP and allied health professionals.
Medication policies and procedures were in place to guide practice. Education and medication competencies were completed by all staff responsible for administration of medicines. The medicines records reviewed include documentation of allergies and intolerances.
The activities programme is facilitated by a diversional therapist. The activities programme provides varied options and activities are enjoyed by the residents. The programme meets the individual recreational needs.
All food is cooked on site by the in-house cook. All residents' nutritional needs were identified, highlighted and choices available and provided. Meals were well presented. There is an improvement required around fridge and freezer temperature monitoring. The previous finding around dietitian review of the menu remains.

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.

The building has a current warrant of fitness. There is an improvement required around annual hoist checks.

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. / Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk.

There are comprehensive policies and procedures that meet the restraint standards. The registered nurse is the restraints co-ordinator and has recently formed a restraint approval group that will meet three monthly. The restraint coordinator provides a monthly report to the quality/staff meetings. There is one resident with restraint and no enablers in use on the day of audit. There is an improvement around the implementation of restraint documentation. Restraint training has been provided annually.

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 infection control programme and its content and detail, is appropriate for the size, complexity, and degree of risk associated with the service. The registered nurse is the infection control co-ordinator. The Infection Control co-ordinator reports monthly surveillance data to the quality/staff meetings. All staff receive infection control education on orientation and annually. Internal audits have been completed with documented outcomes known to staff. The Infection control coordinator is scheduled to attend district health board training in April 2015. Infection control education is provided on orientation and annually.

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 / 11 / 0 / 4 / 2 / 0 / 0
Criteria / 0 / 36 / 0 / 5 / 3 / 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 service has in place a complaints policy and procedure that aligns with Code 10 of the Code of Rights. The manager is responsible for complaints management. There have been no complaints since July 2013. The only complaint was appropriately investigated and managed. A complaints register is maintained. The code of rights, advocacy brochure and complaints forms are displayed in the main entrance. To caregivers and one RN interviewed are knowledgeable in the complaints/concerns procedure.
D13.3h. A complaints procedure is provided to residents within the information pack at entry. Discussion with residents and relatives confirmed they were provided with information on complaints are comfortable approaching management with any concerns/complaints.
Standard 1.1.9: Communication
Service providers communicate effectively with consumers and provide an environment conducive to effective communication. / PA Low / The manager and registered nurse (RN) are readily available to relatives and residents as observed on the day of audit. Relatives (three) and residents (three) interviewed confirmed that the staff and management are approachable and available. There are resident meetings held three monthly with opportunity for feedback on the services. Resident and relative surveys have been completed annually.
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. 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. Relatives and residents interviewed stated they were given sufficient information prior to entry to the service and had the opportunity to discuss services and the admission agreement with management.
D16.1b.ii The 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.
D11.3 The information pack is available in large print and advised that this can be read to residents. Interpreter services are available as required.
Standard 1.2.1: Governance
The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers. / FA / Waverley House is a 20 bed rest home facility. On the day of audit there were 19 rest home residents. The manager leases the building and the business is operated by a wife (manager) /husband (maintenance).
The manager is non-clinical and has had many years’ experience managing rest homes.
ARC, D17.3di (rest home). The manager has maintained at least eight hours annually of professional development activities related to managing a rest home. The manager is supported by a RN Monday to Friday and on-call. The RN is newly appointed December 2014 after graduating with a Bachelor of Nursing. She has links into the district health board (DHB) for nursing advice, clinical support and education.
There is a 2014 business plan and goals that is currently under review. The medication system including administration, reduction of errors and staff education has been the focus for the RN over the last two months. There is evidence of a robust medication system with no findings on the day of audit.
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. / PA Low / There are policies to guide the facility to implement the quality management programme including (but not limited to); quality and risk management programme, committee responsibilities and internal audit schedule. The 2014 internal audit programme has been followed and results discussed at staff meetings. This is an improvement since the previous audit; however improvements are required around corrective actions. The quality review team (manager, RN and senior caregiver) provide reports to the monthly staff meetings. Minutes sighted evidence there is discussion around resident concerns, health and safety, infection control, audit and survey results, corrective actions and improvements. Staff interviewed state they are well informed and receive quality and risk management information at staff meetings. The diversional therapist (DT) conducts surveys six monthly (February and August) as follows: resident care, food satisfaction and activities. The results have been collated and discussed at the resident meetings as evidenced in meeting minutes. This is an improvement since the previous audit.
D5.4. The policies and procedures in place have been reviewed 2014. This is an improvement from the previous audit. Further improvement is required around the contents of policies and procedures.
D19.3: There is a Quality and Risk management programme in place that includes emergency and disaster planning, health and safety and hazard identification. Staff report any hazards identified on the daily maintenance request/hazard form.
D19.2g Falls prevention strategies are in place that includes the analysis of falls incidents and the identification of interventions on a case by case basis to minimise future falls. Prevention strategies (hi-low beds and sensor mats) and corrective actions are documented in the residents care plan.
Standard 1.2.4: Adverse Event Reporting
All adverse, unplanned, or untoward events are systematically recorded by the service and reported to affected consumers and where appropriate their family/whānau of choice in an open manner. / FA / There is evidence of month by month data collection including (but not limited to): falls, falls with injury, skin tears, medication, behavioural incidents and pressure areas. Falls management and prevention includes corrective actions and monitoring requirements which are linked to the long term care plans such as the use of a hi-low bed and sensor mats (link 1.3.6.1). The RN investigates and reviews and implements corrective actions as required of all accident/incident forms. The caregivers interviewed could describe the process for reporting of incidents and accidents.