NZS8134.2:2008 & NZS8134.3:2008

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1 Winchcombe Healthcare Limited CURRENT STATUS: The following summary has been accepted by the Ministry of Health as being an accurate reflection of the Surveillance audit conducted against the Health and Disability Services Standards NZS8134.1:2008; NZS8134.2:2008 & NZS8134.3:2008 on the audit date(s) specified. GENERAL OVERVIEW Cook Street Nursing Centre residents are cared for in a respectful and safe manner in a safe and appropriate environment. Staff is well qualified and staff skill mix ensures continuous and appropriate care delivery. Residents and staff interviewed are complementary of the service and the communication between staff and residents and their families. The organisation has comprehensive quality systems in place to guide care. There have been no changes in contracts or services. Service delivery is resident focused, with comprehensive and holistic assessment by nursing and medical staff as well as appropriate external health professionals as required. Residents have a designated general practitioner (GP) and an assigned registered nurse (RN) keyworker who takes responsibility for ensuring all documentation is current, appropriate reviews are completed and nursing care plans are evaluated and updated within expected timeframes. There is a strong sense of teamwork between all members of the care team, the resident and their whanau. Medication management is supported by policies and procedures, competent staff and the provision of medications in blister packs and individual prescriptions for other medications. The system complies with storage, administration, documentation and disposal requirements. An area of improvement from the last audit relating to the recording of controlled drugs and return of these drugs to the pharmacy when no longer required has been addressed. However, one area of improvement has been raised with respect to the recording of medication allergies and sensitivities on the medication charts. The organisation has not had an issues based audit or complaint lodged with the Health and Disability Commissioner. AUDIT SUMMARY AS AT 23-MAR-11 Standards have been assessed and summarised below: Key Indicator Description Definition

2 Indicator Description Definition Includes commendable elements above the required levels of performance All standards applicable to this service attained with some criteria exceeded attained with all criteria achieved Some minor shortfalls but no major deficiencies and required levels of performance seem achievable without extensive extra activity require specific action to address Major shortfalls, significant action is needed to achieve the required levels of performance attained but with some criteria partially achieved and of negligible or low risk attained but with some criteria partially achieved and of medium, high or critical risk and/or some criteria unattained Some standards applicable to this service unattained 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. 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. 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. action to address

3 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. 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. 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. Winchcombe Healthcare Limited Date of audit: 03-Aug-10 The following summary has been accepted by the Ministry of Health as being an accurate reflection of the certification audit conducted against the Health and Disability Services Standards NZS8134.1:2008;NZS8134.2:2008 & NZS8134.3:2008 on the audit date(s) specified. GENERAL OVERVIEW Cook Street Nursing Care Centre is located in Palmerston North, it has 17 hospital and 13 rest home beds and provides services for over sixty five year old residents. It also has a contract for a respite hospital bed. The organisation is privately owned by a husband and wife and is managed by them. This audit was against both the Health and Disability Sector Standards and the Aged Related Residential Care Contract. There are no outstanding

4 corrective actions from the previous audit and the organisation had not had an issues based audit or a complaint lodged with the office of the Health and Disability Commissioner. SUMMARY Standards have been assessed and summarised below: Key Indicator Description Definition Includes commendable elements above the required levels of performance All standards applicable to this service attained with some criteria exceeded attained with all criteria achieved Some minor shortfalls but no major deficiencies and required levels of performance seem achievable without extensive extra activity require specific action to address Major shortfalls, significant action is needed to achieve the required levels of performance attained but with some criteria partially achieved and of negligible or low risk attained but with some criteria partially achieved and of medium, high or critical risk and/or some criteria unattained Some standards applicable to this service unattained Consumer Rights Indicator 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. action to address Organisational Management Indicator 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. action to address

5 Continuum of Service Delivery Indicator 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. action to address Safe and Appropriate Environment Indicator 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. action to address Restraint Minimisation and Safe Practice Indicator Includes 3 standards with outcomes where: Consumers receive and experience services in the least restrictive manner through restraint minimisation Consumers requiring restraint receive services in a safe manner Consumers requiring seclusion receive services in the least restrictive manner Infection Prevention and Control Indicator Includes 6 standards which require: There is a managed environment, which minimises the risk of infection to consumers, service providers and visitors appropriate to the size and scope of the service. There are adequate human, physical and information resources to implement the infection control programme and meet the needs of the organisation. Documented policies and procedures for the prevention and control of infection reflect current accepted good practice and relevant legislation requirements and are readily available and are implemented in the organisation. These policies and procedures are practical, safe and appropriate/suitable for the type of service provided. The organisation provides relevant education on infection control to all service providers, support staff and consumers. Surveillance for infection is carried out in accordance with agreed objectives, priorities and methods that have been specified in the infection control programme. Acute care and surgical hospitals will have established and implemented policies and procedures for the use of antibiotics to promote the appropriate prudent prescribing in line with accepted guidelines. The service can seek guidance from clinical microbiologists or infectious disease physicians.

6 AUDIT RESULTS Consumer Rights Cook Street Nursing Care Centre provides information and discussion on the Health and Disability Commissioner's (HDC) Code of Health and Disability Services Consumers' Rights (the Code) to ensure residents and their families understand their rights and are able to raise concerns and access support services. The management and staff have a commitment to open disclosure and transparency in all service provision. Residents' cultural and individual values and beliefs are assessed on admission and documented in their plan of care. Staff receive education on supporting cultural and individual values and beliefs at orientation and through the annual education programme. Residents and relatives confirm privacy is respected. There is one corrective action required in relation to advance directives be correctly signed. Organisational Management Cook Street Nursing Care Centre has an organisation wide vision, statement of values and statements regarding residents' respect and rights. The organisation is managed by a Board of Directors who review the scope and provision of services at monthly Board meetings. Cook Street Nursing Care Centre has a quality and risk policy in place with a focus on ongoing quality improvement, innovation, empowerment and team work. Quality principals are included in all activities within the service to monitor outcomes. Staff participate in the quality and risk programme through attendance at meetings and through internal audit. Deficiencies in service delivery are identified through audits and resident and relative feedback, and corrective actions are implemented. The incident and accident reporting and investigation process is linked through the quality and risk system through data collection and analysis. There is a corrective actions required related to ensuring that the organisation's policies and procedures on incident and accident reporting are followed. Cook Street Nursing Care Centre has a workforce of twenty nine staff who are experienced and educated in care of the older person. The rosters show adequate staffing levels to meet resident numbers and acuity, however there is a need to develop a documented process for determining staffing levels and skill mix. Residents and relatives spoken to confirm a high level of satisfaction with the services provided and this is confirmed by results of the resident/relative survey. Continuum of Service Delivery Staff have implemented systems to plan and evaluate the care needs of consumers. The consumers' needs, outcomes and/or goals are documented in the care plans. There is a corrective action required in relation to the need for GPs to document in the clinical record if consumers are assessed as being appropriate to be seen three monthly, rather than monthly. Corrective actions are also required in relation to evidence that consumers and/or families have been involved in the development and review of care and that all consumers have been assessed at the time of admission and on an ongoing basis. Policies and procedures clearly detail service providers' responsibilities. Staff responsible for medicine management have received education in medicines management and have current medicines competencies. Medicine files sighted provide evidence of documentation for

7 consumers' allergies/sensitivities. Two corrective action are made in relation to medicines management; controlled drugs need to be checked by registered staff weekly, as per policy, and controlled drugs from discharged consumers returned to the pharmacy. The food services policies and procedures are appropriate to the service setting. The food service is contracted to Medirest. There is positive feedback from consumers interviewed regarding the food service. A corrective action is made in relation to ensuring that consumers' dietary profiles held in the kitchen are current. Safe and Appropriate Environment There are documented processes for the management of waste and hazardous substances in place. Any incidents are reported on in a timely manner. Service providers have received training and education to ensure safe and appropriate handling. There are appropriate systems to ensure the consumers' physical environment and facilities are fit for their purpose. All buildings, plant and equipment comply with legislation and both the internal and external areas are safe for consumers. Rooms and equipment are well maintained and staff and consumers are able to move freely around the facility. Documented policies and procedures for the cleaning and laundry services are implemented with appropriate monitoring systems in place to evaluate the effectiveness of these services. Documented systems are in place for essential and security services. Staff have been trained accordingly. There are alternative energy and utility sources an appropriate call bell system is available. Security systems are in place. There is a corrective action required in relation to staff being able to access first aid equipment during night duty and that staff following the falls policy. There are two rooms in the rest home close to the hospital wing that have hospital level care patients. The auditors were requested to review the other rest home rooms in relation to the possibility of accommodating further hospital level patients in the future. At the time of the audit, the other rooms in the rest home are not suitable for hospital level care patients. Restraint Minimisation and Safe Practice Cook Street Nursing Care Centre has a restraint policy in place that has a clear definition of restraint and enablers and includes a philosophy of restraint minimisation. All staff receive education on this at orientation and through annual education. Two enablers, at the request of the residents, along with thirteen restraints for safety reasons are in use at the time of audit. Monitoring and evaluation processes are in place for the thirteen restraints in use. Infection Prevention and Control The infection prevention and control programme implemented meets the needs of the organisation and provides information and resources to inform the service providers. Infection prevention and control management systems are documented and implemented to minimise the risk of infection to consumers, service providers and visitors. Policies and procedures are in place for the prevention and control of infection and reflect current accepted good practice. Relevant infection control education is provided to all service providers, support staff and consumers. The type of surveillance undertaken is appropriate for a rest home and hospital. Standardised definitions are outlined in the infection prevention

8 and control policy. Results of surveillance are acted upon, evaluated, and reported to relevant staff in a timely manner.