Selwyn Care Limited - Selwyn Oaks

Selwyn Care Limited - Selwyn Oaks

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:Selwyn Care Limited

Premises audited:Selwyn Oaks

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

Dates of audit:Start date: 26 November 2014End date: 26 November 2014

Proposed changes to current services (if any):An additional two hospital level beds were approved in August 2013. The service requests these beds be approved for dual service. The service is meeting the requirements for rest home/hospital level of care.

Total beds occupied across all premises included in the audit on the first day of the audit:65

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

Selwyn Oaks is a purpose built facility that provides residential care for up to 66 residents at rest home and hospital level care. Occupancy on the day of the audit was 65 residents, 28 at rest home level care and 37 residents at hospital level care. This audit has assessed two previously hospital only beds as suitable for rest home or hospital level residents.

Selwyn Oaks has a village manager who has been in the role for four months and has experience in management, finance and human resources. He is supported by an experienced care lead/registered nurse who has been in the role eight years. There is management support provided by group office. All residents and relatives interviewed spoke very highly about the care and support provided by staff and management.

Three of three shortfalls from the previous certification audit regarding care plans, transcribing and maintenance have been addressed. This audit identified improvement is required around medication documentation and prescribed nutritional supplements.

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.

Selwyn’s mission statement reflects the Selwyn Oaks' objective to deliver services that are responsive to the ageing person and their family. Policies are implemented to support rights such as privacy, dignity, abuse/neglect, culture, values and beliefs, complaints, advocacy and informed consent. The service functions in a way that complies with the Health and Disability Commissioner (HDC) Code of Health and Disability Services Consumers' Rights (the Code). Information about the code of rights and services is readily available to residents and families. Complaints processes are implemented and complaints and concerns are managed and documented. Open disclosure is practiced and this is verified by residents and family interviewed.

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.

Selwyn Oaks has a site specific business plan and goals. There is an established quality and risk management system that supports the provision of clinical care and support. Key components of the quality management system link into quality and staff meetings. An annual resident/relative satisfaction survey is completed and there are regular resident/relative meetings. Quality and risk performance is reported across the facility meetings and also to the organisation's management team. Benchmarking and analysis of quality data occurs on a monthly basis. There are human resources standard operation procedures including recruitment, selection, orientation and staff training and development. Staff, residents and relatives confirm there are adequate staffing levels.

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 low risk.

Selwyn Oaks is implementing the Eden Philosophy and this is documented throughout care plans for the residents. Nursing care plans reviewed were individualised, accurate and up to date. Care plans are goal oriented and reviewed at least six monthly.

Activities provided for residents are varied, age appropriate and include inclusion at local community and entertainment events.

The medication management system is appropriate. Staff responsible for medication administration are trained and monitored. Medications are reviewed by the residents’ general practitioner at least three monthly. Individual resident’s medication charts were sighted. The menu is designed and reviewed by a registered dietitian employed by the contracted food service. Residents have a nutritional profile developed on admission which is reviewed six monthly as part of the care plan review. Residents were complimentary about the meals.

The previous audit findings around care plan documentation and medication transcribing have been addressed.

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.

The building has a current warrant of fitness. There was adequate resident and clinical equipment available on the day of audit. Previous findings around maintenance and repairs have been addressed. The two previously hospital only rooms assessed in this audit are suitable for either rest home or hospital 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.

There is a restraint minimisation standard operation procedure. The procedure includes definitions of restraint and enablers which is congruent with the definition in NZS 8134. The service has a restraint co-ordinator (registered nurse) with defined responsibilities. There were two residents with restraints and one resident with an enabler. Clinical staff attend restraint education. .

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 are appropriate for the size, complexity and degree of risk associated with the service. The infection control manual outlines a comprehensive range of policies, standards and guidelines, training and education of staff and scope of the programme. The infection control coordinator uses the information obtained through surveillance to determine infection control activities, resources and education needs within the facility. This includes audits of the facility, hand hygiene and surveillance of infection control events and infections. The service engages in benchmarking infection control data.

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 / 16 / 0 / 1 / 0 / 0 / 0
Criteria / 0 / 39 / 0 / 1 / 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 1.1.13: Complaints Management
The right of the consumer to make a complaint is understood, respected, and upheld. / FA / Complaints information is provided at entry to the service and is readily available to residents and complies with right 10 of the Code. Residents/family/whanau were supported to discuss the complaint process. The village manager is responsible for ensuring all complaints (verbal and written) are investigated and followed up as per the standard operating procedure for complaints. The care lead (RN) completes initial investigations for all clinical/care concerns and complaints. The complaints register was up to date and recorded the details of the complaint date of corrective actions taken and signed off when resolved. Six complaints during 2014 have been received and all have been documented including follow up letters and resolution that demonstrates that complaints are well managed internally. A record of all complaints per month is entered into the Selwyn database. The number of complaints received each month is reported monthly to care services via the facility benchmarking report. Complaints were discussed at the monthly RN forum, combined quality/ staff meetings and at organizational level. Complaints were also linked to the quality management system and several improvements to the service have occurred such as improvements in the food services.
D13.3h: A complaints procedure was provided to residents within the information pack at entry.
Standard 1.1.9: Communication
Service providers communicate effectively with consumers and provide an environment conducive to effective communication. / FA / There is an open disclosure policy that includes information on the residents or their representative right to full and open disclosure. Incident and accident forms were completed by the registered nurses (RNs). Incident/accident forms sighted evidence the family has been notified. Family notification is also recorded on the personal and telephone conversation record held in the resident file. Family interviewed (two rest home and three hospital) confirmed they are kept informed of their relatives health status and notified of any incidents/accidents. The village manager and care lead (RN) have an open door policy. Resident meetings are held monthly and any issues raised are addressed and fed back to the residents at the next meeting. The residents and families have an opportunity to provide feedback on the service through the annual resident/relative survey. The company engaged an external contractor to collate the results and measure Selwyn Foundation performance against international facilities of similar size. Selwyn Oaks performed top of the Selwyn facilities for 2014.
There is an interpreter policy in place with access to district health board interpreter service.
D12.1 Non-Subsidised residents are advised of the process and eligibility to become a subsidized resident through the admission booklet.
D16.4b Residents (two rest home) and families (five) interviewed confirmed they are kept fully informed.
D11.3 The admission booklet is available in large print and can be read to residents if 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 / Selwyn Oaks is one of 10 facilities in the Selwyn Foundation group. The Selwyn Foundation is a charitable trust governed by appointed board members. The chief executive leads the organizational teams and report to the board. The village manager attends monthly management meetings at head office. A company clinical nurse specialist/nurse practitioner meets with clinical managers/care lead RNs two monthly.
The purpose, values, scope, direction, and goals of the Selwyn Foundation are clearly identified in the business plan for 2014. Selwyn Oaks site specific 2014 business and quality risk plan aligns with the company strategic plan.
Selwyn Oaks provides care for up to 66 residents at rest home or hospital level of care. The occupancy on the day of audit was at 65. The facility is divided into wings for rest home or hospital level. There is one wing of 12 dual purpose beds (two additional dual purpose beds were approved in August 2013 and have been assessed as suitable during this audit).
The village manager (non-clinical) has been in the role for four months. He has a background in the management of acute care facilities, human resource and financial management. He is responsible for the support services and oversees the village. The village manager reports directly to the general manager. The care lead/RN has been in the role at Selwyn Oaks for eight years and has an extensive clinical experience in aged care including palliative care and education. The care lead is responsible for the clinical services and education.
ARC,D17.3di: (rest home), D17.4b (hospital): The manager and care lead/RN have maintained at least eight hours annually of professional development activities related to managing a rest home and hospital.
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. / FA / Selwyn Oaks has a site specific 2014 business plan and a quality and risk management plan in place that is a “working” document with evidence the goals are regularly reviewed (document sighted).
Goals identified for 2014 are as follows;
1. Develop chaplaincy services to meet the spiritual needs of the residents and provide a private space for worship. A private area has been set aside for worship. The chaplain provides a monthly report to the manager. Spiritual needs of the residents are being met.