Athenree Lifecare Limited

Transcription

1 Athenree Lifecare 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 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: Premises audited: Services audited: Athenree Lifecare Limited Athenree Rest Home Hospital services - Medical services; Hospital services - Geriatric services (excl. psychogeriatric); Rest home care (excluding dementia care); Dementia care Dates of audit: Start date: 11 June 2015 End date: 12 June 2015 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: 31 Athenree Lifecare Limited Date of Audit: 11 June 2015 Page 1 of 28

2 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 Athenree Lifecare Limited Date of Audit: 11 June 2015 Page 2 of 28

3 Indicator Description Definition 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 Athenree Lifecare provides hospital, rest home and dementia care for up to 43 residents. During the audit there were 31 residents. The service is managed by an interim facility manager and a clinical nurse manager. This unannounced surveillance audit was undertaken to establish compliance with specified parts of the Health and Disability Services Standard and the district health board contract. The audit process included review of policies and procedures, review of residents and staff files, observations and interviews with residents, family, management, general practitioners, psychiatrist and staff. There were 20 areas identified as requiring improvement at the previous audit; nine of these have been addressed and are now closed. This audit identified 18 areas that either require ongoing improvements (11) or are identified as new issued to be addressed (seven). Athenree Lifecare Limited Date of Audit: 11 June 2015 Page 3 of 28

4 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. Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk. Information regarding the Health and Disability Commissioner's Code of Health and Disability Services Consumers' Rights (the Code), including the facility's complaints process and the Nationwide Health and Disability Advocacy Service, was accessible and is brought to the attention of residents (if able) and their families on admission to the facility. Residents and family members interviewed confirmed their rights were met during service delivery, staff were respectful of their needs and communication was appropriate. Improvements are required with the management of consent processes. The interim facility manager is responsible for management of complaints. A complaints register is maintained although not all complaints and actions taken have been recorded in this register. 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. Athenree Lifecare Limited Date of Audit: 11 June 2015 Page 4 of 28

5 Athenree Lifecare Limited is the governing body and is responsible for the service provided at Athenree Lifecare. Planning documents reviewed included a quality and risk management plan, a business plan, a vision statement, values and philosophy. The previous finding relating to appointment of a suitably qualified facility manager remains. Some improvements have been made with the quality and risk management systems since the last audit. However, there are ongoing improvements still required with some aspects of quality and risk management. There was evidence that quality improvement data has been collected and collated. Adverse events are documented on accident/incident forms. There are policies and procedures on human resources management. Staff records reviewed provided evidence human resources processes have been followed. The areas identified as requiring improvement in the last audit relating to human resource management have been addressed. A new area requiring improvement relating to staff education has been identified during this audit. Education records provided evidence in-service education is provided at least once a week. A documented rationale for determining staffing levels and skill mix was reviewed. The minimum number of staff on duty at any one time is one registered nurse and two care givers. The clinical leader, who is currently acting as the interim clinical manager, is available after hours if required for clinical support. Care staff and residents interviewed reported there is adequate staff available 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. Athenree Lifecare Limited Date of Audit: 11 June 2015 Page 5 of 28

6 Initial assessment, care and support is provided by competent staff, with ongoing evaluations completed by a registered nurse, however, evaluations were not consistently completed within the required timeframe, and therefore, care plans were not consistently updated to reflect the resident s current health status. Input from residents, families and allied health professionals are included in the development of initial care plans. The previous corrective action related to ensuring a review of the activities programme and development of a 24 hour activities plan for residents in the dementia unit, has not been met. There is currently no designated activities coordinator. The service has a documented medication management system, however, there is a requirement to improve the medication charts which were difficult to read, ensure photo identification of residents is on the medication chart, and ensure specimen signatures for visiting medical practitioners are recorded. Nutritional needs of residents are met. Special dietary requirements are catered for and regular monitoring completed. Food services and storage met food safety requirements. 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. Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk. There have been no alterations to the building since the last audit. A current building warrant of fitness was displayed. The areas identified as requiring improvement during the last audit relating to: refurbishment of the facility; damaged chairs and bedroom equipment; the safety of the external area in the dementia unit; and the use of all hospital and rest home bedrooms as dual purpose Athenree Lifecare Limited Date of Audit: 11 June 2015 Page 6 of 28

7 rooms still require improvement. Improvements are also required with the frequency the trial evacuation plan for fire safety have been held. With one exception, all resident bedrooms provide single accommodation. Residents' rooms were observed to be of varying sizes and adequate personal space is provided in bedrooms. Sluice facilities are provided and protective equipment and clothing was provided and used by staff. Chemicals, soiled linen and equipment were safely stored. All laundry is washed on site and cleaning and laundry systems included appropriate monitoring systems are in place to evaluate the effectiveness of these services. 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 are documented guidelines for the use of restraint and enablers, and managing challenging behaviours. Staff received training and demonstrated an understanding of the appropriate and safe use of restraint and enablers to maintain independence. 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. Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk. Athenree Lifecare Limited Date of Audit: 11 June 2015 Page 7 of 28

8 There is a designated infection control coordinator who is responsible for ensuring monthly surveillance is completed and monitoring of infection control practices. There is an improvement required to ensure information related to analysis of infection surveillance data is communicated to staff in a timely manner. Documentation sighted and interview with staff provided evidence that all staff are educated as part of the orientation process. 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 Criteria 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 Criteria Athenree Lifecare Limited Date of Audit: 11 June 2015 Page 8 of 28

9 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 Standard : Informed Consent Consumers and where appropriate their family/whānau of choice are provided with the information they need to make informed choices and give informed consent. Attainment Rating PA Moderate Audit Evidence Areas requiring improvement relating to consent for non-resuscitation were identified during the last audit. The required improvements have been made, however, a new area requiring improvement with consent documentation has been identified (see criterion ). Systems are in place to ensure residents and where appropriate their family are being provided with information to assist them to make informed choices and give informed consent. Written information on informed consent is included in the admission agreement. The acting clinical manager and the interim facility manager reported informed consent was discussed and recorded at the time the resident is admitted to the facility. Standard : Complaints Management The right of the consumer to make a complaint is understood, respected, and upheld. PA Low The interim facility manager is responsible for complaints. Improvements are required with the complaints register (see criterion ). The interim facility manager advised there have been no complaint investigations by the Ministry of Health, Health and Disability Commissioner, District Health Board (DHB), Police, Accident Compensation Corporation (ACC) or Coroner since the Athenree Lifecare Limited Date of Audit: 11 June 2015 Page 9 of 28

10 previous audit at this facility. Complaints policies and procedures are compliant with Right 10 of the Code. Systems are in place to ensure residents and their family are advised on entry to the facility of the complaint processes and the Code. Residents and family interviewed demonstrated an understanding and awareness of these processes. Resident meetings are held monthly and residents are able to raise any issues they have during these meetings. This was confirmed during interview of residents and family and review of resident meeting minutes. Observations provided evidence that the complaint process was readily accessible and/or displayed. Care staff interviewed confirmed complaints information is reported to them via staff meetings. Standard 1.1.8: Good Practice Consumers receive services of an appropriate standard. FA Areas requiring improvement relating to the use of plastic sheeting and draw sheets were identified during the last audit. The required improvements have been made. Systems are in place to ensure staff receive a range of opportunities which promote good practice within the facility. Documentation reviewed provided evidence that policies and procedures are based on evidence-based rationales. Education is provided by specialist educators as part of the in-service education programme. The district health board (DHB) also provides education as part of the in-service education programme. Staff confirmed an understanding of professional boundaries and practice. Standard 1.1.9: Communication Service providers communicate effectively with consumers and provide an environment conducive to effective communication. FA Open disclosure policy and procedures are in place to ensure staff maintains open, transparent communication with residents and their families. There was evidence of communication with the GP and family following adverse events which was recorded on the accident/incident forms and on the resident s family communication record. Residents and family interviewed confirmed that staff communicate well with them. Residents interviewed confirmed that they were aware of the staff that were responsible for their care. The interim facility manager advised access to interpreter services is available if required via the local district health board (DHB), members of staff and the community. They also advised there are currently no residents who require Athenree Lifecare Limited Date of Audit: 11 June 2015 Page 10 of 28

11 interpreter services. The residents and family are informed of the scope of services and any items they have to pay that is not covered by the agreement. Admission agreements were reviewed and this was communicated in each agreement. Standard 1.2.1: Governance The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers. PA Moderate An area requiring improvement relating to the appointment of a suitably qualified and experienced person to manage the service was identified during the last audit. Improvements are still required (see criterion ). Athenree Lifecare Limited is the governing body and is responsible for the service provided at Athenree Rest Home and Hospital. Athenree Lifecare Limited assumed responsibility for the provision of services in December A business plan and a quality and risk management plan were reviewed and include goals. A vision statement, values, and objectives were also reviewed. A management company is contracted to support the governing body and facility personnel. The clinical operations manager from the management company was interviewed and described the strategic direction and vision. Reports to the management company include: reporting on occupancy; staffing; human resource management; environmental and property reports; financial reporting and general comments. The service philosophy is in an understandable form and is available to residents and their family / representative or other services involved in referring residents to the service. Athenree Rest Home and Hospital is currently certified to provide 20 hospital, 10 dementia and 13 rest home level beds. There were 15 hospital, 10 dementia and six rest home level residents during this audit. The service provider has funding contracts with the district health board (DHB) and Ministry of Health to provide aged related residential care (hospital, rest home and dementia). Standard 1.2.3: Quality And Risk Management Systems The organisation has an established, documented, PA Moderate Five criteria were identified during the last audit as requiring improvement. Not all of the required improvements have been made to quality and risk management systems (see criteria , , and ). Athenree Lifecare Limited Date of Audit: 11 June 2015 Page 11 of 28

12 and maintained quality and risk management system that reflects continuous quality improvement principles. A business plan and quality and risk management plan were reviewed. These are used to guide the quality programme and include goals and objectives. New quality systems, including policies and procedures, have been introduced at the facility since December These systems have not been fully implemented. An internal audit programme is in place and internal audits completed in 2014 and 2015 were reviewed, along with processes for identification of risks. A health and safety manual is available. There is a hazard reporting systems available as well as a hazard register. Chemical safety data sheets are available that identify the potential risks for each area of service. Relevant standards are identified and included in the policies and procedures manuals. Policies and procedures reviewed are relevant to the scope and complexity of the service, reflect current accepted good practice, and reference legislative requirements. Policies / procedures are available with systems in place for reviewing and updating the policies and procedures regularly including a policy for document update reviews and document control policy. Staff confirmed during interviews the policies and procedures provide appropriate guidance for the service delivery. Standard 1.2.4: Adverse Event Reporting All adverse, unplanned, or untoward events are systematically recorded by the service and reported to affected consumers and where appropriate their family/whānau of choice in an open manner. FA Staff are documenting adverse, unplanned or untoward events on an accident/incident form. Registered nurses (RN) are advised of all adverse events and undertake an assessment of the resident. The RN is responsible for investigating the event as well as for documenting any corrective actions required and notifying the family. All accident and incident forms are reviewed by the interim clinical nurse manager / clinical leader and signed off when completed. Neurological observations are completed as appropriate. Corrective action plans to address areas requiring improvement were documented on accident/incident form. There was documented evidence of communication with family and GP on the accident/incident forms. There was also evidence of notification to family of any change in the resident s condition. This finding was confirmed during interviews with residents and family members. There is an open disclosure policy. Staff confirmed during interviews that they are made aware of their responsibilities for completion of adverse events through job descriptions and policies and procedures. Staff also confirmed they are completing accident / incident forms for adverse events. Policy and procedures comply with essential notification reporting Athenree Lifecare Limited Date of Audit: 11 June 2015 Page 12 of 28

13 (e.g. health and safety, human resources, infection control). 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. PA Moderate Areas requiring improvement relating to human resource management were identified during the last audit. The improvements required have been made. A new area has been identified as requiring improvement during this audit relating to dementia specific education (see criterion ) Written policies and procedures in relation to human resource management are available. The skills and knowledge required for each position is documented in job descriptions which outline accountability, responsibilities and authority. These were reviewed on staff files along with employment agreements, reference checking, criminal vetting, completed orientations and competency assessments (as appropriate). Copies of annual practising certificates were reviewed for all staff that require them to practice and are current. The clinical and operations manager from HIL Management Services advised the facility manager is responsible for oversight of the in-service education programme. They also advised the clinical manager, when appointed, will provide input in to the education programme. The interim clinical manager advised education is provided weekly. The education planners for 2014 and 2015 were reviewed. Individual staff attendance records and attendance records for each education session were reviewed and provided evidence ongoing education was provided. Competency assessment questionnaires are available and completed competencies are reviewed. An orientation/induction programme is available and new staff are required to complete this prior to their commencement of care to residents. The clinical operations manager advised that staff are orientated for at least two shifts at the beginning of their orientation. The entire orientation process, including completion of competencies, takes up to three months to complete and staff performance is reviewed at the end of this period. Orientation for staff covers the essential components of the service provided. Care staff confirmed they have completed an orientation, including competency assessments (as appropriate). Standard 1.2.8: Service Provider Availability FA There is a documented rationale in place for determining service provider levels and Athenree Lifecare Limited Date of Audit: 11 June 2015 Page 13 of 28

14 Consumers receive timely, appropriate, and safe service from suitably qualified/skilled and/or experienced service providers. skill mixes in order to provide safe service delivery. Registered nurse (RN) cover is provided 24 hours a day. On call after hours registered nurse support and advice is provided by the interim clinical manager. The minimum amount of staff on duty is one registered nurse and two caregivers. There is always at least one care giver on duty in the dementia unit. Care staff interviewed reported there is adequate staff available and that they are able to get through their work. There is at least one staff member with a current first aid certificate on each shift. Residents and family interviewed reported staff provide them with adequate care. Standard : Medicine Management Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines. PA Moderate Staff were observed administering medications during the lunch time medication round and followed correct procedures. Administration records are maintained. Interviews with staff and a review of staff files confirmed that only staff who have been assessed as competent are responsible for medication management. Allergies and sensitivities were identified. Three monthly GP reviews were evident. Individually prescribed medications are used and a blister pack system utilised. Controlled drug logs were maintained with evidence of regular reconciliation sighted. One medication file sampled included a resident who self-administers one form of medication. The resident had been assessed as competent to self-administer medications and the relevant form confirming this was signed by both the resident and the GP. A medication fridge evidenced daily monitoring of temperature was completed. Some residents were prescribed medication that can be used as required, and indications for use were documented. The previous corrective action related to pharmacy input has been met. There have been no adverse events related to medication management. Standard : 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 Residents are provided with a well-balanced diet which meets nutritional requirements. Kitchen staff confirmed there is dietitian input into the menu and the relevant report confirming this was sighted. A four weekly menu is followed and the meals provided on the day were in line with the menu sighted. Residents interviewed were satisfied with the meals provided. Athenree Lifecare Limited Date of Audit: 11 June 2015 Page 14 of 28

15 Dietary assessments are completed on admission and special dietary requirements are highlighted and recorded on documents held in the kitchen. Individual food preference lists were sighted and any allergies identified. Kitchen staff have required food safety qualifications. The kitchen was well stocked, clean and tidy. Fresh fruit and vegetables and other food stuffs were stored appropriately. There was evidence of temperature monitoring and maintenance of a cleaning schedule. Labels and dates are on all containers, and food in the chiller was covered and dated. There have been no reported incidents of residents becoming unwell as a result of poor food handling practices. Standard 1.3.4: Assessment Consumers' needs, support requirements, and preferences are gathered and recorded in a timely manner. PA Low All residents had a nursing assessment completed; however, resident centred goals were not consistently identified. Residents and family interviewed confirmed their involvement in the assessment process on admission; however, there was a lack of ongoing family consultation in order to identify resident centred goals. Clinical staff demonstrated use of a variety of assessment tools to assist in the assessment process. Progress notes and interviews with clinical staff confirmed that assessment is an ongoing process with regular evaluations being completed by the registered nurse (RN). Standard 1.3.6: Service Delivery/Interventions Consumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes. FA The GP confirmed during interview the care they prescribe was completed as requested. They also stated they have confidence that interventions were implemented in an appropriate and timely manner. The RN confirmed the care prescribed by the GP and nursing staff was included in care plans. Care plans reviewed indicated interventions are consistent with best practice. Short term care plans are developed as required, for example, for one resident who recently developed an infection. Documentation is completed daily by care staff who confirmed care was being completed as prescribed. Standard 1.3.7: Planned Activities Where specified as part of the service delivery plan for a consumer, activity requirements are appropriate to PA Moderate The previous corrective action related to providing an activities programme over a 24 hour period for residents in the dementia unit, has not been met (see criterion ) Clinical files showed evidence an activities assessment is completed on Athenree Lifecare Limited Date of Audit: 11 June 2015 Page 15 of 28

16 their needs, age, culture, and the setting of the service. admission, a plan specific to individual needs is maintained, and records of residents participation are maintained. There was no planned activity during the audit, however individuals were observed enjoying television. Observation of residents and interview with family and staff, confirmed this remains an area of required improvement. Standard 1.3.8: Evaluation Consumers' service delivery plans are evaluated in a comprehensive and timely manner. PA Moderate Files sampled included evidence of an evaluation process. Care plan evaluations that were completed described the degree of achievement and progress towards meeting residents desired outcomes. The RN described the process, and evaluations sighted showed clear links to the care plan. Standard 1.4.1: Management Of Waste And Hazardous Substances Consumers, visitors, and service providers are protected from harm as a result of exposure to waste, infectious or hazardous substances, generated during service delivery. FA Areas requiring improvement with the provision of disposable aprons for staff were identified during the last audit. The required improvements have been made. Documented processes are in place for the management of waste and hazardous substances. Material safety data sheets provided by the chemical representative are available and accessible for staff. Education on chemical safety was provided as part of the staff in-service education programme. Staff interviewed reported they have received training and education to ensure safe and appropriate handling of waste and hazardous substances. Sluice facilities are provided for the disposal of waste. Protective clothing and equipment that is appropriate to the risks associated with the waste or hazardous substances being handled were provided and being used by staff. For example, gloves, aprons, and masks were sighted in the sluice room and laundry. Standard 1.4.2: Facility Specifications Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for their purpose. PA Moderate Three criteria were identified as requiring improvement during the last audit. Not all of the required improvements have been made (see criteria and ) Documentation and observations evidenced a current Building Warrant of Fitness is displayed that expires 3 December Visual scan of the facility provided evidence improvements have been made to the storage of furniture and equipment. Corridors are wide enough to allow residents to safely pass each other; safety rails are secure and are appropriately located. Care staff confirmed they have access to appropriate equipment; equipment is Athenree Lifecare Limited Date of Audit: 11 June 2015 Page 16 of 28

17 checked before use; and they are competent to use the equipment. Residents confirmed they know the processes to follow if any repairs/maintenance are required and that requests are appropriately actioned. Residents confirmed they are able to move freely around the facility and that the accommodation meets their needs. Standard 1.4.4: Personal Space/Bed Areas Consumers are provided with adequate personal space/bed areas appropriate to the consumer group and setting. Standard 1.4.6: Cleaning And Laundry Services Consumers are provided with safe and hygienic cleaning and laundry services appropriate to the setting in which the service is being provided. PA Moderate FA Areas requiring improvement were identified during the last audit. The required improvements have not been made (see criterion ) Areas requiring improvement were identified during the last audit relating to cleaning and laundry processes. The required improvements have been made. Cleaning and laundry policy and procedures are available. There are policies and procedures for the safe storage and use of chemicals / poisons. All linen is washed on site and there is adequate dirty / clean flow. The laundry person was interviewed and described the management of laundry including the transportation, sorting, storage, laundering, and the return of clean laundry to the residents. The effectiveness of the cleaning and laundry services is audited via the internal audit programme and completed audits for laundry and cleaning were reviewed. The cleaner was interviewed and described cleaning processes. Observations provided evidence that: safe and secure storage areas are available and staff have appropriate and adequate access to these areas as required; chemicals were labelled and stored safely within these areas; chemical safety data sheets or equivalent were available; appropriate facilities exist for the disposal of soiled water/waste (i.e., sluice room), convenient hand washing facilities are available, and hygiene standards are maintained in storage areas. Residents and family interviewed stated they were satisfied with the cleaning and laundry service and this finding was confirmed during review of the satisfaction survey questionnaires. Athenree Lifecare Limited Date of Audit: 11 June 2015 Page 17 of 28

18 Standard 1.4.7: Essential, Emergency, And Security Systems Consumers receive an appropriate and timely response during emergency and security situations. Standard 3.5: Surveillance Surveillance for infection is carried out in accordance with agreed objectives, priorities, and methods that have been specified in the infection control programme. PA Moderate PA Moderate An area requiring improvement has been identified relating to the frequency trail evacuations have been held (see criterion ). The clinical nurse manager is the infection control coordinator and confirmed a surveillance programme was maintained. Surveillance data was sighted and included infection details related to files sampled. Monthly analysis was completed, however, there was no evidence that information obtained from data being analysed was reported to staff. (See link criterion ). The infection control surveillance is appropriate to the service. There have been no outbreaks since the last audit. Standard 2.1.1: Restraint minimisation Services demonstrate that the use of restraint is actively minimised. FA The use of restraints and enablers are used appropriately. Care plans included alternative interventions to restraint. Monitoring was completed when restraint and enablers were in use. Staff have been provided with education related to the safe management of restraint and managing behaviours of concern. Staff identified that enablers are required to be voluntary and the least restrictive option. Athenree Lifecare Limited Date of Audit: 11 June 2015 Page 18 of 28

19 Specific results for criterion where corrective actions are required Where a standard is rated partially attained (PA) or unattained (UA) specific corrective actions are recorded under the relevant criteria for the standard. The following table contains the criterion where corrective actions have been recorded. Criterion can be linked to the relevant standard by looking at the code. For example, a Criterion : Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of their everyday practice relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights. If there is a message no data to display instead of a table, then no corrective actions were required as a result of this audit. Criterion with desired outcome Attainment Rating Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion The service is able to demonstrate that written consent is obtained where required. PA Moderate Residents / family are provided with various consent forms on admission to complete. Appropriate consent forms were reviewed on residents files. Copies of legal documents such as Enduring Power of Attorney (EPOA) for residents are retained at the facility where residents have named EPOAs and these were reviewed on residents files, where available. Consent forms for a resident have been signed by someone who does not have the legal authority to sign the forms. Provide evidence that staff understand consent processes, including the legal authority conferred on enduring powers of attorney. 60 days Residents and family interviewed confirmed they have been made aware of and understand the principles of informed consent. They confirmed informed consent information has been provided to them and their choices and decisions are acted on. One resident has had consent forms for influenza vaccination and restraint use Athenree Lifecare Limited Date of Audit: 11 June 2015 Page 19 of 28

20 signed by their financial EPOA. The financial EPOA is not the welfare EPOA and the resident has been deemed not competent to consent. Criterion An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken. PA Low There is a complaints folder that includes complaints received. There are nine complaints recorded between 18 December 2014 and 12 May Letters to complainants acknowledging receipt of the complaint were observed but letters providing details concerning the outcome of the investigation were not available. The complaints register does not include all complaints received, dates and actions taken. Provide evidence that all complaints received, dates and actions taken are recorded in the complaints register. 180 days A complaint received 11 May 2015 is not recorded in the complaints register. A complaint received 21 April 2015 does not record the date the actions were taken. Complaint received 12 May 2015 does not have the actions taken recorded. Criterion The organisation is managed by a suitably qualified and/or experienced person with authority, accountability, and responsibility for the provision of services. PA Moderate Athenree Lifecare Limited organisational chart was reviewed and shows the linkage to HIL Management Services Limited. A new facility manager was appointed on 12 December 2014 when Athenree Lifecare Limited assumed responsibility for the provision of services. This person left on 13 May 2015 and since then there have been two interim facility managers appointed. The clinical leader has also been the interim clinical manager since There is no permanent manager in place to manage the service. Provide evidence that a suitably qualified person has been appointed to manage the service. 60 days Athenree Lifecare Limited Date of Audit: 11 June 2015 Page 20 of 28

21 May 2015 when the facility manager left. The clinical operations manager from HIL Management Services Limited reported a permanent facility manager and a clinical manager will be appointed within the next two weeks. They reported offers of employment have been made to two registered nurses to fill both positions. The interim facility manager (FM) is responsible for the day-to-day management of the facility. The interim FM was appointed for a four week period from 2 June 2015 to 3 July The interim FM is a registered nurse with aged care management experience. The interim FM is supported by an interim clinical manager, who is the clinical leader. The interim clinical manager is a registered nurse and is responsible for oversight of clinical care. The annual practising certificate for the interim FM and interim clinical manager were reviewed and are current. There was evidence on the interim clinical manager s file of ongoing education. Criterion The organisation has a quality and risk management system which is understood and implemented by service providers. PA Moderate HIL Management Services quality and risk management systems were introduced in December 2014 when Athenree Lifecare Limited took over the provision of services. Aspects of the HIL quality systems have been implemented. Staff interviewed confirmed they have been made aware of the HIL quality The quality and risk management systems have not been fully implemented. Provide evidence the quality and risk management systems have been fully implemented. 90 days Athenree Lifecare Limited Date of Audit: 11 June 2015 Page 21 of 28

22 systems. Criterion Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers. PA Moderate Meeting minutes reviewed did not provide evidence of reporting / feedback on completion of internal audits and various clinical indicators. Meeting minutes for 2014 and 2015 were reviewed. There was evidence that quality improvement data has been collected and collated on various registers. May 2015 clinical indicators have been analysed by the interim facility manager. Quality improvement data is not being analysed to identify trends and is not being reported to staff. Provide evidence quality improvement data is being analysed to identify trends and this information is being reported to staff. 90 days Criterion A process to measure achievement against the quality and risk management plan is implemented. PA Low Various meetings are held. Meeting minutes were reviewed and indicated quality meetings are not being held on a regular basis. There is an internal audit programme in place and internal audits completed in 2015 were reviewed. Internal audits have not been completed and meetings have not been held as per the quality improvement plan introduced in December Provide evidence internal audits are completed and quality meetings are held as per the quality improvement plan. 180 days Criterion A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented. PA Moderate Meeting minutes and completed internal audits were reviewed. These do not consistently record the person responsible, the timeframe for completion, and evidence of monitoring and sign-off of the corrective action plan. Corrective action plans have not been consistently developed to address areas identified as requiring improvement. Provide evidence corrective action plans are developed, implemented, monitored and signed off as completed where areas are identified as requiring improvement. 90 days Athenree Lifecare Limited Date of Audit: 11 June 2015 Page 22 of 28

23 Criterion A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers. PA Moderate The clinical operations manager advised they are currently negotiating with an aged care education provider to provide the New Zealand Qualifications Authority approved aged care education modules. They also reported that all care staff working in the facility will be required to complete the dementia specific modules. Five of the seven staff working in the dementia unit has evidence they have completed the dementia specific learning modules. Staff are supported to complete education via external education providers. Not all staff working in the dementia unit have commenced or completed the dementia specific agedcare education modules. Provide evidence all staff working in the dementia unit have commenced or completed the dementia specific aged-care education modules. 60 days Criterion A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines. PA Moderate Medicines have been prescribed by the GP; however, six of twelve medication charts were difficult to read due to being faxed to the pharmacy repeatedly as prescriptions were updated. The faxed copies had been signed by the GP. There were up to three copies of medication charts remaining in the medication folder which had not been crossed off to indicate it had been updated. Specimen signatures of prescribing doctors were not recorded. Photo identification of residents were available, however, the photos were not attached to the medication charts i) Six of twelve medication charts were difficult to read and had multiple copies retained in the medication folder. ii) No Medication charts included photo identification. iii) Specimen signatures of prescribing doctors were not recorded. i) Ensure all medication charts in use are legible and current ii) photo identification is on each medication chart and specimen signatures for prescribing doctors are recorded. 60 days Criterion The needs, outcomes, and/or goals of consumers are identified via the PA Low There was evidence in two resident s clinical files of resident/family involvement in care planning. Family Four clinical files did not identify resident centred goals. Provide evidence resident centred goals are clearly identified and documented Athenree Lifecare Limited Date of Audit: 11 June 2015 Page 23 of 28

24 assessment process and are documented to serve as the basis for service delivery planning. members and residents stated their input is sought when planning care. Four clinical files did not include documentation which showed evidence of resident/family involvement in the assessment process. in consultation with the resident/family. 180 days Criterion Activities are planned and provided/facilitated to develop and maintain strengths (skills, resources, and interests) that are meaningful to the consumer. PA Moderate Clinical files and documentation showed evidence of assessments and participation records for previously planned activities. The last activities coordinator has left within the last two weeks and has not been replaced yet. The clinical operations manager advised they are currently advertising for a replacement. Some families interviewed described a lack of planned activity for residents. i) There is no structured activities programme specific to individual needs in the dementia unit. ii) There is no planned activities programme provided. iii) There is no activities coordinator. i)provide an activities programme to cover a 24 hour period in the dementia unit ii) an activities programme for all residents at the facility and appoint a designated activities coordinator. 60 days Criterion Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome. PA Moderate There was evidence in three clinical files that an evaluation of care had been completed, however, three clinical files did not have an evaluation completed within the identified timeframes. Evaluations of care plans are not consistently completed within required timeframes. Complete care plan evaluations within the required timeframes. 60 days Criterion Where progress is different from expected, the service responds by initiating changes to the service delivery plan. PA Moderate Three clinical files contained care plans which reflected current needs of residents, however three residents care plans had not been updated to reflect current needs identified within progress notes. Three clinical files had not been updated to accurately reflect the current needs of residents. Ensure all care plans accurately reflect the current needs of residents. 60 days Athenree Lifecare Limited Date of Audit: 11 June 2015 Page 24 of 28