Heritage Healthcare Limited - Capella House

Heritage Healthcare Limited - Capella House

Introduction

This report records the results of a Partial 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: Heritage Healthcare Limited

Premises audited: Capella House

Services audited: Hospital services - Geriatric services (excl. psychogeriatric); Dementia care

Dates of audit: Start date: 1 October 2015 End date: 1 October 2015

Proposed changes to current services (if any): Renovating a building previously used as an aged care facility to a 9 bed dual purpose wing and a 19 bed specialist secure dementia unit.

Total beds occupied across all premises included in the audit on the first day of the audit: 0

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

A partial provisional audit was undertaken at Capella House to establish the level of preparedness of the provider to provide new hospital, rest home and secure dementia level of care service for up to 28 residents. There will be a 19 bed secure specialist dementia unit and a 9 bed dual purpose wing (suitable for rest home or hospital level of care). The facility has not commenced service delivery and was unoccupied at the time of audit.

The audit process included observation of the environment, interviews with the owner and staff, and review of documented processes to ensure they are appropriate for the employment, orientation and training of staff to provide specialist dementia, hospital and rest home level of care.

There are systems in place for the provision of safe medicine management, food services and infection prevention and control.

The building has previously been used as an aged care facility, with a complete refurbishment and fit out having been carried out by the new owner. Prior to commencement of service delivery the service is required to gain a building Code of Compliance and complete the fencing and furnishing of the building.

Consumer rights

Not applicable to this partial provisional audit.

Organisational management

Systems are documented which define the scope, direction and objectives of the service and the monitoring and reporting processes. There is a transitional plan for the gradual and staged admission of residents. The service is implementing staff training and education to promote a service that promotes positive wellbeing for residents living with dementia.

The owner is the facility/business manager with the overall responsibly for the running of the service. There is a clinical nurse manager with appropriate qualifications and experience who has previously managed a dementia service. The clinical manager’s role is documented as having overall responsibility for the running of the clinical service. The clinical manager’s role is currently going through the recruitment process.

The service has a staffing plan that documents there will be sufficient staffing numbers for the commencement of service delivery. The documented human resources management system provides for the appropriate employment of staff and on-going training processes. A system has been developed for the orientation, induction and ongoing education programme. Staff will have received or undergo specific education related to dementia care.

Continuum of service delivery

Medicine management policies, procedures and processes comply with current legislative requirements and safe practice guidelines. There are processes to ensure that all staff who administer medications will be assessed as competent to do so.

The menu has been reviewed by a dietitian. There will be food and nutritional snacks available 24 hours day for the residents living in the dementia unit.

Safe and appropriate environment

The renovations and fit out to the building are almost complete. The service is still required to complete the fencing and the furnishing of the building. These are planned to be competed in the next week, with the service due to commence service delivery by end of October 2015.

The dual purpose wing and the dementia unit areas are separated. The planned environment in both areas are based on dementia friendly design principles. All rooms are single occupancy and ensure physical privacy is maintained. There are processes in place to protect residents, visitors, and staff from exposure to waste and infectious or hazardous substances. Laundry services will be conducted onsite in the dual purpose section of the service. There are processes in place to provide safe and hygienic cleaning and waste management services. Chemicals will not be stored in the dementia unit.

The services has yet to gain the building Code of Compliance and have the evacuation scheme approved by the fire service, this will be required prior to the commencement of service delivery. There are documented systems in place for essential, emergency and security services, including a comprehensive disaster and emergency management plan.

The facility has an appropriate call system installed. There is access to the external garden areas which have been developed based on ‘dementia friendly’ design principles. The physical environment minimises the risk of harm, promotes safe mobility, aids independence and is appropriate to the needs of the residents who are prone to wander. The secure specialist dementia unit is separated from the other section of the facility.

There are adequate toilets, showers and bathing facilities located throughout the facility that provides adequate privacy and signage.

Restraint minimisation and safe practice

Not applicable to this audit.

Infection prevention and control

The infection prevention and control policies, procedures and programme sighted identifies how the provider intends to provide a controlled and safe environment. Policy identified external advice and support will be sought when required.

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 / 13 / 0 / 2 / 0 / 0 / 0
Criteria / 0 / 32 / 0 / 3 / 0 / 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 1.2.1: Governance
The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers. / FA / The transition plan documents processes for the delivery of rest home/hospital and dementia level of care for up to 28 residents.
The goals and philosophy of the service are clearly documented and are based on flexible and consumer directed care.
Capella House is governed by the owner/registered nurse, who owns two other aged care facilities. The owner will initially work as the clinical nurse manager, until a suitably qualified and experienced clinical nurse manager is recruited (this process has commenced).
The owner/registered nurse has over 15 years’ experience in aged care having owned the two other facilities for the last nine years. The owner has completed training in management in aged care, as well as other related topics. The manager is a member of an aged care association, and receives ongoing education and updates related to the aged care sector. The assistant manager has competed ongoing education related to aged care management.
Standard 1.2.2: Service Management
The organisation ensures the day-to-day operation of the service is managed in an efficient and effective manner which ensures the provision of timely, appropriate, and safe services to consumers. / FA / During temporary absences of the manager, the assistant manager (who is non clinical) will take on the management roles. The owner expressed confidence in the assistant manager to take on the manager’s role. The assistant manager’s job description describes their roles and responsibilities. When the clinical nurse manager is appointed, it is intended that this role will take on the clinical aspects of the mangers role.
Standard 1.2.7: Human Resource Management
Human resource management processes are conducted in accordance with good employment practice and meet the requirements of legislation. / FA / The owner has already recruited and allocated 19 staff ready for the commencement of service delivery at Capella House. The service is planning for all care staff to complete the dementia unit standards.
Human resources policies describe good employment practices that meet the requirements of legislation, as confirmed in the staff files reviewed. Professional qualifications are validated, including evidence of registration and scope of practice for service providers. The owner ensures that staff who require practising certificates have them validated annually. Practising certificates were sighted for the employed staff who require them.
Prior to commencement of service delivery, there is a planned orientation, induction and training programme to the layout of the dementia unit. The training plan includes the management of challenging behaviours and specific approaches for dementia care.
The education calendar sighted has all the required topics required to meet contractual agreements. This includes ensuring ongoing interRAI competencies.
Standard 1.2.8: Service Provider Availability
Consumers receive timely, appropriate, and safe service from suitably qualified/skilled and/or experienced service providers. / FA / There is a clearly documented staffing transition plan that initially documents the staffing levels from the anticipated initial six residents up to full capacity. As the owner operates another two aged care facilities, there is access to a staff pool of over 90 caregivers. The owner has recruited staff on a part time and casual basis over the past few months in anticipation that these staff will commence work at Capella House. When Capella House opens, the owner has already chosen staff that have the required dementia training, or who are working towards completing dementia unit standards. There are sufficient nurses and caregivers already recruited to meet the needs of up to 19 residents. There is a recruitment plan for when the service has over 19 residents. Three of the RNs planned to work at the service have an interRAI competency assessment.
The owner will initially be the clinical nurse manager, until they recruit a suitably qualified and experienced clinical nurse manager (in the process of recruitment at the time of audit). The draft rosters and staffing policy identify that there will be a registered nurse on duty at all times. The draft rosters evidenced there will be a diversional therapist employed for seven days a week. There are sufficient numbers of cooking and cleaning staff to meet the needs of the service and residents.
Standard 1.3.12: Medicine Management
Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines. / FA / There were no medications at the time of audit. The service has appropriate policies and procedures for safe medication management that reflect legislative and best practice guidelines. The service is planning to use a pre-packed medication dispensing system. All medications will be securely stored in a locked space in the dual purpose section of the service.
Staff who assist in medication management will have a medication competency prior to commencing.
Self-administration of medications is not appropriate for residents living in the dementia unit. There are processes in place for residents in the dual purpose wing to self-administer their medications if they are assessed as competent to do so.
The template for the medication charts has sections for the required information of the medication prescription and signing sheets.
Standard 1.3.13: Nutrition, Safe Food, And Fluid Management
A consumer's individual food, fluids and nutritional needs are met where this service is a component of service delivery. / FA / The menu is similar to the meal plan used at the owners other aged care facilities, and has been reviewed by a dietitian in the last two years. The menu has a four week rotational cycle with seasonal variations for summer and winter. The menu has other variations, with the addition of finger foods that would be appropriate for residents living in the dementia unit. There is a fridge located within the dementia unit, which will provide access to nutritional snacks 24 hours a day.
The menu and kitchen manual provides guidance on any additional or modified nutritional needs of residents. The service has a nutritional profile, which will be completed for all residents. This identifies any likes, dislikes, allergies and specialised nutritional needs.