Millvale House Waikanae Limited

Millvale House Waikanae 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:Millvale House Waikanae Limited

Premises audited:Millvale House Waikanae

Services audited:Hospital services - Psychogeriatric services;

Dates of audit:Start date: 9 December 2015End date: 9 December 2015

Proposed changes to current services (if any):A 15 bed dual purpose wing has been reconfigured into a secure 15 bed psychogeriatric wing increasing the total number psychogeriatric beds to 30 as of November 2015. The new wing was verified at this audit as suitable to provide psychogeriatric services.

Total beds occupied across all premises included in the audit on the first day of the audit:30

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

Millvale House is part of the Dementia Care New Zealand group, which is privately owned. The service is certified to provide psychogeriatric level of care for up to 30 residents. On the day of the audit, there were 30 residents.

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. The audit process included the review of policies and procedures, the review of residents’ and staff files, observations, and interviews with relatives, general practitioner, management and staff.

The clinical manager is a registered nurse who has been in the role two years. She is supported by an operations coordinator. The regional clinical manager visits the site regularly. The team are supported by Dementia Care NZ, quality systems manager and an education co-ordinator.

Relatives commented positively on the standard of care and services provided at Millvale House.

The service has addressed the one previous certification finding around restraint monitoring and the one finding from the previous partial provisional audit around medication dates. The service has reconfigured the 15-bed dual-purpose wing into a 15-bed psychogeriatric level of care wing. The bedrooms and communal areas within the wing have been completely refurbished. The outdoor area of the reconfigured wing has been landscaped and provides a secure environment for the residents.

There were no findings at this surveillance audit. The service has maintained continuous improvement ratings around governance, quality data, and the quality management programme.

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.

The service has an open disclosure policy stating residents and/or their representatives have a right to full and frank information and open disclosure from service providers. There is a complaints policy and an incident/accident reporting policy. Family members are informed in a timely manner when their family members health status changes. The complaints process and forms for completion were viewed on the family notice board in the entrance foyer to the facility. Brochures are also freely available for the Health and Disability, and advocacy service with contact details provided. Information on how to make a complaint and the complaints process are included in the admission booklet and displayed throughout the facility.

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. / All standards applicable to this service fully attained with some standards exceeded.

The quality and risk programme includes a variety of quality improvement initiatives, which are generated from meetings, resident, family and staff feedback and through the internal audit systems. Millvale House has a current business and quality plan to support quality and risk management at each facility. Millvale House implements an internal audit programme and collates data for comparisons against other Dementia Care New Zealand facilities. There is a benchmarking programme in place across the organisation. Relative surveys are undertaken annually. Incidents and accidents are appropriately managed. Staff requirements are determined using an organisation service level/skill mix process and documented. There is a documented rationale for staffing. Staffing rosters indicate there are suitable staff on duty to care for residents. The service has a documented and implemented training plan.

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. / Standards applicable to this service fully attained.

Assessments, care plans, interventions and evaluations are the responsibility of the registered nurses. The multidisciplinary team and families are involved in the review of the care plan. InterRAI assessments are linked into the comprehensive care plan. A 24-hour multidisciplinary care plan identifies a resident’s behaviours and, activities or diversions that are successful. There is at least a three monthly resident review by the medical practitioner and psychogeriatrician as required.
The activity team provides a seven-day programme of meaningful activities that meets the recreational needs and preferences of each resident. Individual activity plans are developed in consultation with the family and resident (as appropriate).
The medication management system meets legislative requirements. Registered nurses are responsible for the administration of medications. Education and medication competencies are completed annually. The GP reviews the resident’s medication at least three monthly.

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.

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 policy and procedures are in place. The definitions of restraints and enablers are congruent with the definitions in the restraint minimisation standard. The service had no residents using enablers and thirteen residents using restraints. Staff regularly receive education and training on restraint minimisation and managing challenging behaviours.

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 coordinator (registered nurse) is responsible for the collation and reporting of infections. There are policies and guidelines in place for the definition and surveillance of infections. The infection control coordinator uses the information obtained through surveillance to determine infection control activities and education needs within the facility.

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 / 2 / 16 / 0 / 0 / 0 / 0 / 0
Criteria / 3 / 38 / 0 / 0 / 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 / The service has a complaints policy and procedures in place and residents and their family/whānau are provided with information on the complaints process on admission through the information pack. Complaint forms are available at the entrance of the service. Three caregivers, one registered nurse (RN) and one clinical manager interviewed were aware of the complaints process and to whom they should direct complaints. A complaints folder is maintained with a current complaints register. There have been three complaints recorded for 2015, year to date. All are well documented including investigation, follow-up and resolution. Family members advised that they were aware of the complaints procedure and how to access forms. Complaints are discussed at the monthly quality management meetings and staff meetings.
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 in place, information on which is included at the time of admission. A site-specific introduction to the dementia unit booklet provides information for family, friends and visitors visiting the facility. Family members have regular contact with the operations coordinator and clinical manager who have an open-door policy. Incident forms reviewed identified family were informed. Three family members interviewed stated that they are always informed when their family member's health status changes or of any other issues arising. There is an interpreter policy in place with information included in the admission booklet.
Standard 1.2.1: Governance
The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers. / CI / Dementia Care New Zealand Limited (DCNZ) is the parent company under which Millvale House Waikanae operates. Millvale House Waikanae provides psychogeriatric level care for up to 30 residents. There were 30 residents in the home on the day of audit. All residents were under the ARHSS contract.
DCNZ operates nine aged care facilities throughout NZ providing rest home, hospital, medical, dementia and psychogeriatric level care. There is a corporate structure in place, which includes the two directors and a governance team of managers and coordinators. There is a regional clinical manager North Island and a regional clinical manager South Island. There is a business plan 2015-2016 in place for all facilities.
An operations coordinator and a clinical manager/RN manage Millvale House Waikanae on a daily basis. The operations coordinator has been in the role for three months and has previously worked for the organisation as a caregiver. The clinical manager (registered nurse) is responsible for the clinical oversight of the service. The clinical manager has been in the role since September 2013. An organisational quality systems manager, a regional clinical manager and an education coordinator also support the operations coordinator and clinical manager.
The vision and values of the organisation underpin the philosophy of the service, which includes ‘creating a loving, warm and homely atmosphere where each person is supported to experience each moment richly”. The philosophy of the service also includes providing safe and therapeutic care for residents with dementia that enhances their quality of life and minimises risks associated with their confused states.
The organisation holds an annual training day for all operations managers and all clinical managers.
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. / CI / The organisation wide risk management plan describes objectives, management controls and assigned responsibility. Progress with the quality and risk management programme is monitored through the quality meeting. The operations coordinator and clinical manager log and monitor all quality data. Meeting minutes are maintained and staff are expected to read the minutes. Minutes sighted have included actions to achieve compliance where relevant. Quality improvement (QI) reports are provided to the monthly quality meeting. A number of meetings includes discussion of quality data and follow-through of quality improvements. Staff interviewed confirmed involvement and feedback around the quality management system.
Discussions with staff confirmed their involvement in the quality programme. Data is collected on complaints, accidents, incidents, infection control and restraint use. The internal audit schedule has been completed as per the 2015 schedule. Areas of non-compliance identified at audits have had corrective action plans developed and signed as completed. Benchmarking with other facilities occurs on data collected.
The annual survey conducted in September 2015 evidences that families/EPOA are overall very satisfied with the service. Survey evaluations have been conducted for follow-up and quality improvements developed where required. Residents and families are informed of survey outcomes via meetings and newsletters. Corrective actions and quality improvements are developed following all meetings, audits, surveys, with evidence of actions completed and sign-off of all required interventions.
The service has comprehensive policies and procedures to support service delivery. Policies and procedures align with current best practice. A document control policy outlines the system implemented whereby all policies and procedures are reviewed regularly.
Falls prevention strategies are in place that includes assessment of risk, medication review, vitamin D administration, physiotherapy assessments and involvement, exercises/physical activities, training for staff on falls risk and prevention, and awareness of environmental hazards. There is monthly analysis of falls incidents and the identification of interventions on a case-by-case basis to minimise future falls.