Oceania Care Company Limited - Eden Lifestyle Care & Village

Oceania Care Company Limited - Eden Lifestyle Care & Village

Introduction

This report records the results of aSurveillance 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 byCentral Region's Technical Advisory Services 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:Oceania Care Company Limited

Premises audited:

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

Dates of audit:Start date: 21 January 2016End date: 21 January 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:68

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

Eden Lifestyle Care and Village (Oceania) can provide care for up to 70 residents requiring care at either rest home or hospital level with 68 residents on the day of audit. This surveillance audit has been undertaken to establish compliance with a sub-set of the relevant Health and Disability Services Standards and the district health board contract.

The audit process included the review of policies and procedures, the review of residents and staff files, observations and interviews with residents, family, management, staff and a medical officer.

The business and care manager is responsible for the overall management of the facility and is supported by the clinical manager, regional and executive management team. Service delivery is monitored.

This surveillance audit identified improvements required to the following: the quality and risk management programme, training, wound management, assessments and administration of medication.

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 interviewed are able to demonstrate an understanding of residents' rights and obligations including the complaints process. Information regarding the complaints process is available to residents and their family and complaints reviewed are investigated with documentation completed and stored in the complaints folder. Staff communicate with residents and family members following any incident with this recorded in the resident file. Residents and family state that the environment is conducive to communication including identification of any issues.

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 medium or high risk and/or unattained and of low risk.

Eden Lifestyle Care and Village has documentation of the Oceania quality and risk management system that supports the provision of clinical care and support. Policies are reviewed and business status reports allow for the monitoring of service delivery. Benchmarking reports include clinical indicators, incidents/accidents, infections and complaints with an internal audit programme implemented. Corrective action plans are documented with evidence at times of resolution of issues when these are identified.

Staffing levels are adequate across the service with human resource policies implemented. This includes evidence of recruitment and staffing. Rosters indicate that staff are replaced when on leave.

Improvements are required to analysis of quality data, documentation of resolution of issues and to training for staff around pressure injuries.

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.

There is evidence that each stage of service provision is developed with resident and/or family input and coordinated to promote continuity of service delivery. The residents and family interviewed confirmed their input into care planning and access to a typical range of life experiences and choices.

A sampling of residents' clinical files validated the service delivery to the residents. Assessments and care plans are completed within the required timeframes, with the exception of the interRAI assessments. Long term care plans are evaluated six monthly. Where progress is different from expected, this is recorded on a short term care plan. Short term care plans are not consistently being evaluated. Some aspects of the wound management system are identified as areas requiring improvement.

Planned activities are appropriate to the group setting. The residents and family interviewed confirm satisfaction with the activities programme. Individual activities are provided either within group settings or on a one-on-one basis.

There is an appropriate medicine management system in place. Staff responsible for medicine management attend medication management in-service education and have current medication competencies. The residents self-administering medicines do so according to policy. There are areas identified as requiring improvement around discontinued medication, photo identification and medication fridge temperatures.

Food, fluid, and nutritional needs of residents are provided in line with recognised nutritional guidelines and additional requirements/modified needs are being met. Residents have a role in food choices. There is a central kitchen and on site staff that provide the food service. The kitchen staff have completed food safety training.

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.

There is a current building warrant of fitness. A planned and reactive maintenance programme is in place with issues addressed as these arise. Residents and family interviewed describe the environment as appropriate with indoor and outdoor areas that meet their needs.

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 minimisation policy and procedures and the definitions of restraint and enabler are congruent with the restraint minimisation and safe practice standard. The approval process for enabler use is activated when a resident voluntarily requests an enabler to assist them to maintain independence and/or safety. There were six residents using restraint and no residents requiring enablers on audit day.

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.

Surveillance of infections is occurring according to the descriptions of the process in the infection control programme. The type of surveillance undertaken is appropriate to the size and complexity of this service. Standardised definitions are used for the identification and classification of infection events, indicators or outcomes.

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 / 0 / 5 / 0 / 0
Criteria / 0 / 35 / 0 / 1 / 5 / 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 1.1.13: Complaints Management
The right of the consumer to make a complaint is understood, respected, and upheld. / FA / The organisation’s complaints policy and procedures is in line with the Health and Disability Commissioner (HDC) Code of Health and Disability Services Consumers' Rights (the Code) and includes periods for responding to a complaint. Complaint’s forms are available in the facility.
A complaints register is in place and the register includes the date the complaint was received; the source of the complaint; a description of the complaint; and the date the complaint was resolved. Evidence relating to each lodged complaint is held in the complaint’s folder. Two complaints were tracked and the review indicates that all timeframes taken to inform the family and resolve the issues raised were met.
Residents and family members all state that they would feel comfortable complaining.
There has been one complaint forwarded by the Health and Disability Commission since the previous audit lodged in 2015. The Health and Disability Commissioner’s office has responded with a request for further information (HDC) and the complaint continues to be addressed.
Standard 1.1.9: Communication
Service providers communicate effectively with consumers and provide an environment conducive to effective communication. / FA / Accidents/incidents, the complaints procedure and the open disclosure procedure alert staff to their responsibility to notify family/enduring power of attorney of any accidents/incidents that occur. These procedures guide staff on the process to ensure full and frank open disclosure is available.
If the resident has an incident, accident, a change in health or a change in needs, then family are informed, as confirmed in a review of accident/incident forms and in the resident files.
Files reviewed include documentation around family contact. Interviews with family members confirm they are kept informed. Family confirm that they are invited at least six monthly to the care planning meetings for their family member.
Interpreting services are available when required from the District Health Board. The business and care manager states that families are involved in resident care and can interpret when required. There are no residents requiring interpreting services at the time of the audit. All residents interviewed confirm that staff are approachable and communicate in a way that meets their needs. The business and care manager has an open door policy that allows residents, family and staff to communicate any issues at any time.
An information pack is available in large print and staff interviewed advised that this could be read to residents.
Staff training records includes training around connecting with people and communication.
Standard 1.2.1: Governance
The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers. / FA / Eden Lifestyle Care and Village is part of the Oceania Care Company Limited with the executive management team including the chief executive officer and general manager, regional operational manager and clinical and quality manager providing support to the service on the day of the audit. Communication between the clinical and quality manager, the regional operations manager and the business and care manager takes place on a regular basis (at least once a month) with more support provided as required.
Oceania has a clear mission, values and goals and staff interviewed are able to describe these. These are displayed in the service.
The facility can provide care for up to 70 residents requiring rest home or hospital level of care (all dual-purpose beds). During the audit, the occupancy was 68; (33 residents requiring rest home level care and 35 requiring hospital level care). All residents at the time of the audit were over 65 years.
The business and care manager has been with the service for three months having had management experience at another Oceania facility for over eight years. The business and care manager is a registered nurse and is a member of the ADHB steering committee for falls and pressure injuries. The clinical manager provides clinical oversight of the service.
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 Moderate / Eden Lifestyle Care uses the Oceania quality and risk management framework that is documented to guide practice. The business plan is documented and reporting occurs through the business status reports. This includes financial monitoring, review of staff costs, progress against the healthy workplace action plan, review of complaints, incidents, relationships and market presence action plan and review of physical products.
The service implements organisational policies and procedures to support service delivery. All policies are subject to reviews as required, with all policies current. Policies are linked to the Health and Disability Sector Standard, current and applicable legislation, and evidenced-based best practice guidelines. Policies are readily available to staff and new and revised policies are signed by staff to say that they have read and understand them. The policy around pressure injuries has been reviewed and is in draft. This has been sent to business and care managers to make final comment.
Service delivery is monitored through complaints, review of incidents and accidents, surveillance of infections and implementation of an internal audit programme. Quality improvement data can be analysed through meetings and benchmarking and corrective action plans are documented. Improvements are required to analysis and discussion of data and documentation of evidence of resolution of issues.