Golden Concept Group (NZ) Limited - Eversleigh Hospital

Transcription

1 Golden Concept Group (NZ) Limited - Eversleigh Hospital Introduction This report records the results of a Provisional 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: Premises audited: Services audited: Golden Concept Group (NZ) Limited Eversleigh Hospital Hospital services - Geriatric services (excl. psychogeriatric); Rest home care (excluding dementia care) Dates of audit: Start date: 5 March 2015 End date: 6 March 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: 30 Golden Concept Group (NZ) Limited - Eversleigh Hospital Date of Audit: 5 March 2015 Page 1 of 31

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 Golden Concept Group (NZ) Limited - Eversleigh Hospital Date of Audit: 5 March 2015 Page 2 of 31

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 Eversleigh Hospital is privately owned and operated and provides cares for up to 36 residents requiring rest home and hospital level care. On the day of the audit there were 30 residents. This audit was undertaken to establish the level of preparedness of a prospective provider to provide a health and disability service and to assess conformity prior to a facility being purchased. The audit was conducted against the relevant Health and Disability standards and the contract with the District Health Board. The audit process included a review of policies and procedures; the review of resident s and staff files, observations and interviews with residents, relatives, staff and management. The current manager is well experienced and qualified for the role and will be remaining in position with the new owners. The potential owners, Golden Concept E Limited is wholly owned by Golden Concept (NZ) Limited a group who operate one other aged residential facility which provides specialist dementia services. The organisation has comprehensive policies and procedures with which to guide staff. It is Golden Concept E Limited s intention to facilitate a smooth transition between owners and to minimise disruption to staff and residents. The organisation has a plan for the transition and change of ownership which will see the implementation of Golden Concept (NZ) Limited policies and procedures which will be reviewed to include policies that relate specifically to the provision of care to residents who require hospital level services. This audit has identified areas for improvement related to the quality system, the timeliness of documentation, the activities programme and the temperatures of kitchen refrigerators. Golden Concept Group (NZ) Limited - Eversleigh Hospital Date of Audit: 5 March 2015 Page 3 of 31

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 low risk. Staff demonstrate an understanding of residents' rights and obligations. This knowledge is incorporated into their daily work duties and caring for the residents. Residents receive services in a manner that considers their dignity, privacy and independence. Written information regarding consumers rights is provided to residents and families. Cultural values and beliefs are identified and incorporated into the residents care plans. Evidence-based practice is evident, promoting and encouraging good practice. Residents and family are kept informed. The rights of the resident and/or their family to make a complaint is understood, respected and upheld by the service. There is an improvement related to the timeliness of residents signing admission agreements. The prospective provider understands the need to provide services that respect consumers rights. 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 low risk. The prospective provider of Eversleigh Hospital is an existing provider of aged care services. The organisation has a transition plan in place to facilitate the smooth transition between owners with the least disruption of services for staff and residents, which Golden Concept Group (NZ) Limited - Eversleigh Hospital Date of Audit: 5 March 2015 Page 4 of 31

5 includes the on-going employment of the current manager and the appointment of a clinical manager who will be additional to the existing team of registered nurses. The facility will be overseen by the directors and Golden Concept (NZ) Limited s policies and procedures will be implemented immediately following the change of ownership. Services are planned, coordinated, and are appropriate to the needs of the residents. The facility manager who is also a registered nurse with a current practising certificate is responsible for the day-to-day operations of the facility. The facility manager is supported by a senior nurse. Goals are documented for the service with evidence of annual reviews. A quality and risk management programme is in place. Health and safety processes are in place. Missing is evidence that quality and risk data is being trended and evaluated. In addition, corrective actions in 2014 were archived before being signed off by the facility manager to evidence implementation. Residents receive appropriate services from suitably qualified staff. Human resources are managed in accordance with good employment practice. An orientation programme is in place for new staff. On-going education and training for staff is in place. Staffing levels are linked to resident acuity. The facility manager is supported by a registered nurse on site 24 hours a day, seven days a week. The residents files are appropriate to the service type and are compliant with legislative requirements. 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. Entry to the service is managed primarily by the facility manager. Comprehensive service information is available. Initial assessments are completed by the senior registered nurse. Care plans and evaluations are completed by registered nurses. Care Golden Concept Group (NZ) Limited - Eversleigh Hospital Date of Audit: 5 March 2015 Page 5 of 31

6 plans are written in a way that enables all staff to clearly follow their instructions. Residents and family interviewed confirmed they were involved in the care planning and review process. Each resident has access to an individual and group activities programme. There is a medicines management system in place based on legislative and contractual requirements. General practitioners review residents at least three monthly or more frequently if needed. Meals are prepared on site. The menu is varied and appropriate. Individual and special dietary needs are catered for. Alternative options are able to be provided. Residents and relatives interviewed were complimentary about the food service. Improvements are required to the timeliness of documentation in the areas of care planning, weighing of residents, medicines management, and the activities programme. 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. A current building warrant of fitness is posted in a visible location. Reactive and preventative maintenance is carried out. Chemicals are stored securely and staff are provided with personal protective equipment. Hot water temperatures are monitored and recorded. Medical equipment and electrical appliances have been calibrated by an authorised technician. Residents rooms are of sufficient space to allow services to be provided and for the safe use and manoeuvring of mobility aids. There are sufficient communal areas within the facility including lounge and dining areas, and small seating areas. There is a designated laundry and cleaner s room. Golden Concept Group (NZ) Limited - Eversleigh Hospital Date of Audit: 5 March 2015 Page 6 of 31

7 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 policy that included comprehensive restraint procedures and aligns with the standards. A register is maintained with all residents with restraint or enablers which is overseen by the senior nurse. There were five residents requiring restraints and six residents using enablers. The service reviews restraint as part of the quality management and staff are trained in 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. Standards applicable to this service fully attained. Infection prevention and control management systems are in place to minimise the risk of infection to consumers, service providers and visitors. Documented policies and procedures are in place for the prevention and control of infection and reflect current accepted good practice and legislative requirements. Infection control education is provided to all service providers as part of their orientation and also as part of the on-going in-service education programme. The type of surveillance undertaken is appropriate to the size and complexity of the organisation. Results of surveillance are acted upon, evaluated and reported to relevant personnel. Golden Concept Group (NZ) Limited - Eversleigh Hospital Date of Audit: 5 March 2015 Page 7 of 31

8 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 () 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 Golden Concept Group (NZ) Limited - Eversleigh Hospital Date of Audit: 5 March 2015 Page 8 of 31

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 1.1.1: Consumer Rights During Service Delivery Consumers receive services in accordance with consumer rights legislation. 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 Low Audit Evidence The Health and Disability Commissioner (HDC) Code of Health and Disability Consumers Rights (the Code) poster is displayed in a visible location in English and in Maori. Policy relating to the Code is implemented and staff can describe how the Code is incorporated in their everyday delivery of care. Staff receive training about the Code during their induction to the service, which continues through in-service education and training. Interviews with care staff (three caregivers, two registered nurses, one activities coordinator) reflected their understanding of the key principles of the Code. The prospective provider has an understanding of consumers rights and is familiar with the need to ensure residents receive services that comply with consumer rights legislation. Informed consent processes are discussed with residents and families on admission. Written consents are included in the admission agreement and signed for in a separate informed consent form. Service agreements were signed for five of six residents. Advanced directives are signed for separately. Caregivers and the senior nurse interviewed confirmed verbal consent is obtained when delivering care. The service Golden Concept Group (NZ) Limited - Eversleigh Hospital Date of Audit: 5 March 2015 Page 9 of 31

10 Standard : Advocacy And Support Service providers recognise and facilitate the right of consumers to advocacy/support persons of their choice. Standard : Links With Family/Whānau And Other Community Resources Consumers are able to maintain links with their family/whānau and their community. Standard : Complaints Management The right of the consumer to make a complaint is understood, respected, and upheld. acknowledges the resident is for resuscitation in the absence of a signed directive by the resident. The general practitioner (GP) discusses resuscitation with families/epoa where the resident was deemed incompetent to make a decision. Discussion with family members identified that the service actively involves them in decisions that affect their relative s lives. Information on advocacy services through the Health and Disability Commissioner s (HDC) Office is included in the resident information pack that is provided to residents and their family on admission and is documented on the compliment/complaint form. Pamphlets on advocacy services are also available at the entrance to the facility. Interviews with the residents and relatives confirmed their understanding of the availability of advocacy (support) services. Staff receive education and training on the role of advocacy services. The service has an open visiting policy. Residents may have visitors of their choice at any time. The service encourages the residents to maintain relationships with their family, friends, and community groups by encouraging their attendance at functions and events, and providing assistance to ensure that they are able to participate in as much as they can safely and desire to do. This includes residents going out with their families, visits to the local library or visits to a local café for a coffee. Bus trips are available twice per month. Resident/family meetings are held quarterly. A complaints policy is in place. The complaints procedure is provided to residents and relatives at entry to the service. Discussions with the residents and relatives confirmed they were provided with information on complaints and complaints forms. Complaints forms are in a visible location at the entrance to the facility adjacent to a suggestions/complaints box. These forms identify in writing time frames for responding to a complaint as defined by the Health and Disability Commissioner. A register of all complaints, both verbal and written is maintained by the facility manager using a month by month complaints log. Complaints are trended over a year. Documentation including follow up letters and resolution demonstrates that complaints are being managed in Golden Concept Group (NZ) Limited - Eversleigh Hospital Date of Audit: 5 March 2015 Page 10 of 31

11 Standard 1.1.2: Consumer Rights During Service Delivery Consumers are informed of their rights. Standard 1.1.3: Independence, Personal Privacy, Dignity, And Respect Consumers are treated with respect and receive services in a manner that has regard for their dignity, privacy, and independence. accordance with guidelines set forth by the Health and Disability Commissioner. Follow-up documentation to the complainant includes information relating to the Health and Disability Advocacy Service. One complaint, lodged with Waitemata District Health Board (Waitemata DHB) in October 2014, remains open. This complaint, lodged by family relates to staffing levels, food and the activities programme. Corrective actions that are being implemented are being signed off by the Waitemata DHB portfolio manager during random visits to the facility. The facility manager reports that the portfolio manager will be returning again to follow-up on implemented corrective actions. One complaint received in 2015 was reviewed with evidence of appropriate follow-up actions taken and has been closed. Details relating to the Code are included in the resident information pack that is provided to new residents and their family. This information is also available at reception. The facility manager or the registered nurse (RN) discusses aspects of the Code with residents and their family on admission. Discussions relating to the Code are held during the resident/family meetings. All seven residents (four rest home level and three hospital level) and four family (one rest home level and three hospital level) interviewed report that the residents rights are being upheld by the service. Interviews with residents and family also confirmed their understanding of the Code and its application to aged residential care. Residents rights policy links to maintaining the privacy, dignity and respect of the residents. The residents personal belongings are used to decorate their rooms. All rooms were single occupancy during the audit. A double room is available if needed. Discussions of a private nature are held in the resident s room. The caregivers interviewed report that they knock on bedroom doors prior to entering rooms, ensure doors are shut when cares are being given and do not hold personal discussions in public areas. They report that they encourage the residents' independence by encouraging them to be as active as possible. All of the residents interviewed confirmed that their privacy is being respected. Guidelines on abuse and neglect are documented in policy. Staff Golden Concept Group (NZ) Limited - Eversleigh Hospital Date of Audit: 5 March 2015 Page 11 of 31

12 Standard 1.1.4: Recognition Of Māori Values And Beliefs Consumers who identify as Māori have their health and disability needs met in a manner that respects and acknowledges their individual and cultural, values and beliefs. Standard 1.1.6: Recognition And Respect Of The Individual's Culture, Values, And Beliefs Consumers receive culturally safe services which recognise and respect their ethnic, cultural, spiritual values, and beliefs. Standard 1.1.7: Discrimination Consumers are free from any discrimination, coercion, harassment, sexual, financial, or other exploitation. Standard 1.1.8: Good Practice Consumers receive services of an appropriate standard. receive education and training on abuse and neglect. Any suspected instances of abuse or neglect are dealt with in a prompt manner by the facility manager. The service is committed to ensuring that the individual interests, customs, beliefs, cultural and ethnic backgrounds of Maori are valued and fostered within the service. They value and encourage active participation and input of the family/whanau in the day-to-day care of the resident. During this audit there were no Maori residents living at the facility. Maori consultation is available through Auckland University of Technology s Tepuna Haupora and Maori staff who are employed by the service. Staff receive education on cultural awareness during their induction to the service and as a regular in-service topic. All care staff interviewed are aware of the importance of whanau in the delivery of care for Maori residents. A family/whanau room is available. The service is committed to ensuring that each resident remains a person, even in a state of physical or mental decline. The service identifies the residents personal needs and desires from the time of admission. This is achieved with the resident, family and/or their representative. Cultural values and beliefs are discussed and incorporated into the residents care plans. All residents and relatives interviewed confirmed they were involved in developing the resident s plan of care, which included the identification of individual values and beliefs. Professional boundaries are defined in job descriptions. Staff are issued with a code of conduct during their induction to the facility. Interviews with all care staff confirmed their understanding of professional boundaries including the boundaries of the caregivers role and responsibilities. Professional boundaries are reconfirmed through education and training sessions, staff meetings, and performance management if there is infringement with the person concerned. Evidence-based practice is evident, promoting and encouraging good practice. Registered nursing staff are available seven days a week, 24 hours a day. A general practitioner (GP) visits the facility once a week Golden Concept Group (NZ) Limited - Eversleigh Hospital Date of Audit: 5 March 2015 Page 12 of 31

13 Standard 1.1.9: Communication Service providers communicate effectively with consumers and provide an environment conducive to effective communication. Standard 1.2.1: Governance The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers. and is available 24 hours a day. Residents identified as stable are reviewed by the general practitioner (GP) every three months. The majority of residents are seen monthly by the GP. The service receives support from Waitemata District Health Board. The gerontology nurse specialist and wound care specialist come on-site regularly to assist with complex cases and provide education and training for staff. Physiotherapy services are available four six hours a week. There is a regular in-service education and training programme for staff. A podiatrist is onsite every six-weeks and a hairdresser is available fortnightly. The service has links with the local community and encourages residents who are able to remain independent. The GP interviewed is satisfied with the level of care that is being provided. Policies and procedures relating to accident/incidents, complaints and open disclosure policy alert staff to their responsibility to notify family/next of kin/enduring power of attorney. Accident/incident forms have a section to indicate if next of kin have been informed (or not) of an accident/incident. Ten accident/incident forms that were reviewed across the rest home and hospital identified family are kept informed. All of the family interviewed stated that they are kept informed when their family member s health status changes. An interpreter policy and contact details of available interpreters is available. Interpreter services are available. One resident who is Russian-speaking has family and staff available who speak Russian. The information pack is available in large print and is read to residents who require assistance. Non-Subsidised residents are advised in writing of their eligibility and the process to become a subsidised resident should they wish to do so. The residents and family are informed prior to entry of the scope of services and any items they have to pay that are not covered by the agreement. This provisional audit was conducted to assess the preparedness of new owners for the facility and included an interview with the new owner, review of the transition plan and interviews with Kiwi Family Group Limited s current facility manager, senior nurse and care staff. The new Golden Concept Group (NZ) Limited - Eversleigh Hospital Date of Audit: 5 March 2015 Page 13 of 31

14 Standard 1.2.2: Service Management The organisation ensures the day-to-day operation of the service owners, Golden Concept E Ltd are wholly owned by Golden Concept Group (NZ) Ltd. Golden Concept Group (NZ) Limited operate one other aged care facility in Auckland that provides services to residents requiring specialist dementia care. The current organisation has comprehensive policies and procedures with which to guide staff. It is Golden Concept E s intention to facilitate a smooth transition between owners and to minimise disruption to staff and residents. It has developed a transition plan for the transition period and the change of ownership which will see the implementation of Golden Concept E policies and procedures. The facility has been privately owned and operated by Cressida Health Care who now trade as Kiwi Family Group Limited. The service provides care for up to 36 residents at hospital (geriatric and medical) and rest home level care. On the day of the audit, there were 30 residents in total (5 residents at rest home level and 25 residents at hospital level).two of the seven rest home level beds were occupied by residents living in the two serviced apartments within the care facility. The service has been managed by a facility manager who is a registered nurse with a current practising certificate. She has been in this position for over two years. She has over 20 years experience in managing aged care facilities and will continue to manage the facility following the change of ownership. The facility manager reports to the general manager of Kiwi Family Group currently on a variety of management issues. The current Kiwi Family Group Limited s strategic plan and quality and risk management plans for the Kiwi Family Group have been implemented. Golden Concept E has developed a transition plan and has a quality policy that includes their annual quality plan. These plans will be used throughout the transition period. The facility manager receives support from a team of registered nurses, caregivers, an administrator and other support staff. The facility manager has completed at least eight hours of training related to management of a rest home and hospital in The general manager for the organisation is responsible for administrative responsibilities in the absence of the facility manager. Golden Concept Group (NZ) Limited - Eversleigh Hospital Date of Audit: 5 March 2015 Page 14 of 31

15 is managed in an efficient and effective manner which ensures the provision of timely, appropriate, and safe services to consumers. Standard 1.2.3: Quality And Risk Management Systems The organisation has an established, documented, and maintained quality and risk management system that reflects continuous quality improvement principles. PA Low The facility manager, who is a practising registered nurse, covers for the senior registered nurse and vice versa. The current facility manager is a registered nurse with a current practising certificate. She will be remaining in the position following the change of ownership and will continue to work full-time. The clinical manager role is under discussion and a clinical manager is intended to be appointed with hours to be determined. The clinical manager will manage the clinical aspects of the hospital and rest home residents. The on call arrangements will be managed 24 hours a day, 7 days a week by the facility manager as currently happens. The facility manager will make additional arrangements when she is unable to be on call. The facility manager will report to the managing director. If the facility manager is temporarily absent then the newly appointed clinical manager or the existing senior nurse will assume the responsibilities of the role on a temporary basis. Depending on the length of absence and the reasons for the absence, Golden Concept E may choose to make alternate arrangements and appoint a facility manager to cover the role to provide more stability. A risk management and quality policy is in place for the organisation. Policies and procedures and associated implementation systems are readily accessible to staff. These documents have been developed inline with current accepted best and/or evidenced based practice and are reviewed a minimum of two-yearly. A document management process controls policies and procedures. The review process is managed by the general manager and facility manager. Staff are required to sign that they have read any new policies and/or revised policies. Changes to policy are also discussed in the monthly staff meetings. There is evidence of the regular (monthly) monitoring of accident/incidents, complaints, restraints, infections and identified hazards. In addition, an internal audit programme is in place. Data are shared in staff meetings (evidenced in the monthly meeting minutes). Missing is the trending and evaluation of accident and incident data. Corrective actions are determined where opportunities for improvement are identified but were not being signed off by the facility manager to Golden Concept Group (NZ) Limited - Eversleigh Hospital Date of Audit: 5 March 2015 Page 15 of 31

16 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. 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. evidence implementation. Health and safety procedures cover hazard identification, management of hazards, monitoring of hazards, and review of hazards. A workplace hazard inspection is included in the internal audit schedule. Topics relating to health and safety (e.g. hazard identification) are included in staff meetings. The prospective purchaser has developed a transition plan, which identifies current and anticipated organisational risks. These risks relate to occupancy, organisational risks, human resource related risks, clinical risks and environmental/service related risks. The transition plan includes a range of identified actions to prevent or mitigate the identified risks. An annual quality policy (plan) has been developed which includes an internal audit schedule. All policies, procedures and forms will be replaced on the day of change of ownership. The generic policies procedure and forms used at the prospective provider s other residential facility will be used at Eversleigh and additional polices will be added that relate to the clinical care of hospital level residents. Individual incidents and accidents are documented by staff with evidence of appropriate follow-up by a registered nurse including clinical observations, development of short term care plans and review by the GP if medically indicated. Data that is collected is entered into a monthly report but trends have not been identified (link to finding ). The facility manager is aware of statutory and regulatory obligations for essential notification requirements. Current practising certificates are held on site for the registered nurses and enrolled nurses and visiting health professionals. Human resources policies include recruitment, selection, orientation and staff training and development procedures. Six staff files were randomly selected for audit (two RNs, three caregivers, one cleaner). All six staff files contain signed employment contracts and signed job descriptions, completed orientation programmes and annual performance appraisals. The orientation programme is developed specifically to the worker type (e.g. RN, caregiver). Care staff interviewed report new staff are adequately orientated to the service. Golden Concept Group (NZ) Limited - Eversleigh Hospital Date of Audit: 5 March 2015 Page 16 of 31

17 Standard 1.2.8: Service Provider Availability Consumers receive timely, appropriate, and safe service from suitably qualified/skilled and/or experienced service providers. Standard 1.2.9: Consumer Information Management Systems Consumer information is uniquely identifiable, accurately recorded, current, confidential, and accessible when required. There is evidence of education and training programmes for staff that exceeds eight hours annually. RNs are encouraged to attend training provided by Waitemata DHB. The prospective purchaser plans to make minimal changes to existing staffing arrangements. The intention is to retain the existing staffing arrangements and to retain the services of the general practitioner and the pharmacy. The positions of clinical manager, activities coordinator and the maintenance person will be reviewed. The intention is to add a clinical manager position, review the hours or the activities coordinator and review how maintenance is carried out across the new and existing facility. There is an organisational staffing policy that aligns with contractual requirements and includes skill mix. The facility manager is an RN with a current practising certificate. An RN is available on site 24 hours a day, seven days a week. Caregivers are adequately staffed throughout the facility. Staffing is flexible to meet the acuity and needs of the residents. A casual pool of RN staff is available as needed. Agency staff is used as a last resort. Activities staff are scheduled four hours a day, five days a week (link to finding ). Dedicated staff are employed for cleaning and laundry services. Interviews with residents and families confirmed staffing overall was satisfactory. The prospective purchaser has a skill mix policy and the intention is to staff according to resident acuity and contractual obligations. The existing roster of registered nurses and caregivers will continue. The residents files are appropriate to the service type. Residents entering the service have all relevant initial information recorded into the resident s individual record by nurses within 24 hours of entry. An initial support plan is also developed in this time. Information containing personal resident information is kept confidential and cannot be viewed by other residents or members of the public. Residents files are protected from unauthorised access by being held in a secure room. Archived records are held in separate locked and secure areas. Golden Concept Group (NZ) Limited - Eversleigh Hospital Date of Audit: 5 March 2015 Page 17 of 31

18 Standard 1.3.1: Entry To Services Consumers' entry into services is facilitated in a competent, equitable, timely, and respectful manner, when their need for services has been identified. Standard : Transition, Exit, Discharge, Or Transfer Consumers experience a planned and coordinated transition, exit, discharge, or transfer from services. Standard : Medicine Management Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines. PA Low Residents files demonstrate service integration. Entries are legible, timed, dated and signed by the relevant carer including designation. The service has comprehensive admission policies and processes in place. Residents receive an information pack outlining services able to be provided, the admission process and entry to the service. The facility manager screens all potential residents prior to entry and records all admission inquires. Residents and relatives interviewed confirmed they received information prior to admission and had the opportunity to discuss the admission agreement with the clinical manager. The admission agreement form in use aligns with the requirements of the ARC contract. Exclusions from the service are included in the admission agreement. The information provided at entry includes examples of how services can be accessed that are not included in the agreement. The prospective purchaser plans to use their existing policies, procedures and forms for all new admissions from the day of change of ownership. There are policies in place to ensure the discharge of residents occurs correctly. Residents who require emergency admissions to hospital are managed appropriately and relevant information is communicated to the DHB. The service ensures appropriate transfer of information occurs using the DHB documentation system. Relatives interviewed confirmed they were kept well informed about all matters pertaining to their family members especially if there is a change in their condition. The medicines management policies and procedures comply with legislation and guidelines with the exception of the process of documenting verbal medicine orders given by general practitioners. Medicines stock is appropriately stored. Medicines administration practice observed complied with policy. Registered nurses and senior caregivers administer medicines. Competencies are assessed by the facility manager and the senior nurse. The registered nurse on duty reconciles the deliveries of newly received medicines. Medication charts are written correctly by medical practitioners with the exception of verbal orders and there was evidence of three monthly reviews by the GP. Medicine administration charts sampled were correctly completed by nursing staff. Standing orders are not used and no resident was self- Golden Concept Group (NZ) Limited - Eversleigh Hospital Date of Audit: 5 March 2015 Page 18 of 31

19 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. PA Low administering medicines on audit day. The service has a contract with a pharmacy (which the new owner s plan to continue). The contacted pharmacist last performed an onsite audit in March The prospective purchaser is not planning to alter the actual process of medicine management. Policies will change to that used by the prospective purchaser. There is a functional kitchen and the majority of food is cooked on site and this arrangement will continue with the prospective purchaser. The kitchen includes a gas cooker, an electric oven, slow cookers and a microwave. There is a food service manual in place to guide staff. A resident nutritional profile is developed for each resident on admission and provided to the kitchen staff. The kitchen is able to meet the needs of residents who need special diets and the cooks work closely with the RNs on duty. The facility employs two cooks. One cook works Monday to Friday seven hours a day from 6.30 am. The other works Saturday and Sundays for 4 hours a day. The Monday to Friday cook prepares some of the weekend food. The facility employs kitchen hands Monday to Sunday for 6 hours from 7.30 am and additional kitchen hands are employed 2.5 hours in the evening to provide the evening meal. The main meal is served at lunchtime. The main cook has food safety qualifications and the other weekend cook is in the process of completing her training online. The cooks follow a rotating seasonal menu, which has been developed according to the nutritional guidelines for the elderly and was last, reviewed 14 February The DHB monitor is requiring a further review this month by the 16 March The menu will be reviewed by the prospective purchaser. The temperatures of refrigerators, freezers and cooked foods are monitored and recorded. The temperatures of the refrigerators are not consistently being maintained within accepted levels and the temperatures of cooked foods are not being recorded prior to service. There is special equipment available for residents if required. All food is stored appropriately. Residents and the family/whanau members interviewed were very happy with the quality and variety of food served. Standard 1.3.2: Declining Referral/Entry To Services The facility manager has not declined a prospective resident for admission. If this was to occur the facility manager would record the Golden Concept Group (NZ) Limited - Eversleigh Hospital Date of Audit: 5 March 2015 Page 19 of 31

20 Where referral/entry to the service is declined, the immediate risk to the consumer and/or their family/whānau is managed by the organisation, where appropriate. reason for declining service entry to residents and communicate the decision to residents/family/whanau as appropriate. Anyone declined entry is referred back to the referring agency for appropriate placement and advice. Standard 1.3.4: Assessment Consumers' needs, support requirements, and preferences are gathered and recorded in a timely manner. Standard 1.3.5: Planning Consumers' service delivery plans are consumer focused, integrated, and promote continuity of service delivery. Standard 1.3.6: Service Delivery/Interventions Consumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes. All appropriate personal needs information is gathered during admission in consultation with the resident and their relative where appropriate (with the exception of resident weights refer ). Assessments were reviewed at least six monthly or when there was a change to a resident s health condition in files sampled. Care plans are developed on the basis of these assessments. The long term care plans reviewed described the support required to meet the resident s goals and needs and identified allied health involvement. Residents and their family/whanau are involved in the care planning and review process. Short term care plans are in use for changes in health status. Staff interviewed reported they found the plans easy to follow. Registered nurses and caregivers follow the plan of care and report progress against the plan at each shift handover. If external nursing or allied health advice is required the registered nurses will initiate a referral (e.g., to the Gerontology Nursing Service Waitemata DHB who were onsite on the day of audit and interviewed). The Gerontology Nurse reported that the facility manager and senior nurse use the service often to gain specialist advice and there is an established good working relationship in place. If external medical advice is required this will be actioned by the resident s GP. Registered nurses have access to sufficient medical supplies (e.g., dressings). Sufficient continence products are available and resident files include a continence assessment and plan. Specialist continence advice is available as needed and this could be described. Wound assessment, monitoring and wound management plans are in place for seven residents which are being appropriately managed. There were no residents with major wounds. The RNs have access to specialist nursing wound care management advice. Golden Concept Group (NZ) Limited - Eversleigh Hospital Date of Audit: 5 March 2015 Page 20 of 31

21 Standard 1.3.7: Planned Activities Where specified as part of the service delivery plan for a consumer, activity requirements are appropriate to their needs, age, culture, and the setting of the service. PA Low One activities coordinator is employed Monday to Friday from am to 12 noon then she starts again at 1 pm to 2.30pm when she finishes for the day. She coordinates the activities programme for all residents. The activities coordinator has participated in a one day professional development day in 2014 and participates in local diversional therapy training groups. She has a valid first aid certificate. The activities coordinator is employed as a caregiver prior to commencing the activities role and is employed as a caregiver to assist with feeding residents during their lunch time meal. Each resident has an individual activities assessment on admission and from this information an individual activities plan is developed. The individual activity plan is evaluated and reviewed but this does not occur at the same time the resident s care plan is reviewed. The group activities programme is run Monday to Friday from to 12 noon and then 1 pm to 2 pm leaving 30 minutes for administration management. The surveillance audit finding that the programme did not align with the activity co-ordinator actual working hours in order to deliver a meaningful programme. This finding was signed off by DHB monitor on 8 December Each resident is free to choose whether they wish to participate in the group activities programme or their individual plan. Participation is monitored by the activities coordinator. Group activities during the week include a 90 minute session of bingo, an activity (e.g. drawing), a bus trip (the facility leases a large bus with a driver twice a month for community outings), or exercise. The group afternoon session includes 60 minutes of music. Individual residents are walked by the activities coordinator each afternoon during the 60 minute session. Residents and families interviewed expressed concern that the group activities programme was limited. The prospective purchaser is aware of the issues related to the activities programme and intends to review the hours of the activities coordinator and review both the individual and group programmes currently being provided. Standard 1.3.8: Evaluation All initial care plans are evaluated by the registered nurse (RN) within Golden Concept Group (NZ) Limited - Eversleigh Hospital Date of Audit: 5 March 2015 Page 21 of 31

22 Consumers' service delivery plans are evaluated in a comprehensive and timely manner. Standard 1.3.9: Referral To Other Health And Disability Services (Internal And External) Consumer support for access or referral to other health and/or disability service providers is appropriately facilitated, or provided to meet consumer choice/needs. 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. Standard 1.4.2: Facility Specifications Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for their purpose. three weeks of admission. The long term care plan is evaluated at least six monthly or earlier if there is a change in health status. The activities plan is not reviewed at the same time (Link ). The facility manager maintains a list of all residents due for review to ensure reviews occur in a timely manner. There is a three monthly review by the GP and every second review coincides with the six monthly reviews. All changes in health status are documented and followed up. Care plan reviews are signed by a registered nurse. Short term care plans are evaluated and resolved or added to the long term care plan if the problem is on-going. Where progress is different from expected, the service responds by initiating changes to the care plan. The service facilitates access to other medical and non-medical services. Referral documentation is maintained on resident files. The nurses initiate referrals to nurse specialists and allied health services (e.g., the Specialist Gerontology Nurse Specialist and the dietitian). Other specialist medical referrals were made by the GPs. Referrals and options for care were discussed with the family as evidenced in interviews and medical notes. The staff provided examples of where a resident s condition had changed and the resident was reassessed. Waste management procedures are linked to maintenance and chemical safety policies. All chemicals are labelled with manufacturer labels. There are designated areas for storage of cleaning/laundry chemicals and chemicals were stored securely. Laundry and sluice rooms are locked when not in use. Product use charts and manufacturer safety data sheets are in place. Gloves, aprons, and goggles are available for staff. Safe chemical handling training has been provided. The service displays a current building warrant of fitness which expires on 1 June Hot water temperatures are checked monthly. Medical equipment and electrical appliances have been tested and tagged and calibrated. The service hires a van for use twice monthly, for residents outings. Regular and reactive maintenance occurs. Residents were observed to mobilise safely within the facility. There are sufficient seating areas throughout the facility. The exterior has been well maintained with safe paving, outdoor shaded seating, lawn and gardens. Caregivers interviewed confirmed there was adequate equipment to Golden Concept Group (NZ) Limited - Eversleigh Hospital Date of Audit: 5 March 2015 Page 22 of 31