Manis Aged Care No 1 Limited

Transcription

1 Manis Aged Care No 1 Limited Current Status: 1 September 2014 The following summary has been accepted by the Ministry of Health as being an accurate reflection of the Provisional Audit conducted against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008) on the audit date(s) specified. General overview Wakefield Rest Home provides residential care for up to 22 rest home residents and occupancy on the day of the audit was 17. The facility is currently operated by Wakefield Rest Home Limited. This provisional audit is undertaken to establish the extent to which the existing provider conforms to the requirements of the Health and Disability Services Standards and the District Health Board (DHB) funding contract prior to a change in ownership. This audit also establishes how well prepared the prospective provider is to provide a health and disability service. One of the directors for the prospective provider, Manis Aged Care No 1 Limited, was interviewed during this audit. There are 12 areas identified during this audit that require improvement. The required improvements relate to: collation of the resident and family survey results; development and implementation of corrective action plans to address any areas identified as requiring improvement; completion of adverse event forms; evidence of criminal vetting for staff; the provision of inservice education and completion of competency assessments; management of resident information systems including residents documentation and a resident register; management of residents care plans including completion and evaluation of risk assessments and evaluation of activities careplans; medication management; food service management; and the provision of specialised education for the infection control co-ordinator.

2 HealthCERT Aged Residential Care Audit Report (version 4.2) Introduction This report records the results of an audit against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008) of an aged residential care service provider. The audit has been conducted by an auditing agency designated under 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). It is important that auditors restrict their editing to the content controls in the document and do not delete any content controls or any text outside the content controls. Audit Report Legal entity name: Certificate name: Designated Auditing Agency: Manis Aged Care Limited Manis Aged Care Limited - Wakefield Rest Home Health Audit (NZ) Limited Types of audit: Provisional Audit Premises audited: Wakefield Rest Home Services audited: Rest home care (excluding dementia care) Dates of audit: Start date: 1 September 2014 End date: 2 September 2014 Proposed changes to current services (if any): Total beds occupied across all premises included in the audit on the first day of the audit: 17

3 Audit Team Lead Auditor XXXXX Hours on site Other Auditors XXXXX Total hours on site Technical Experts Consumer Auditors Total hours on site Total hours on site Hours off site Total hours off site Total hours off site Total hours off site Peer Reviewer XXXXX Hours 3 Sample Totals Total audit hours on site 30.5 Total audit hours off site 18 Total audit hours Number of residents interviewed 5 Number of staff interviewed 9 Number of managers interviewed 2 Number of residents records reviewed Number of medication records reviewed Number of residents records reviewed using tracer methodology 5 Number of staff records reviewed 7 Total number of managers (headcount) 17 Total number of staff (headcount) 13 Number of relatives interviewed 1 1 Number of GPs interviewed 1 2

4 Declaration I, XXXXX, Managing Director of Auckland hereby submit this audit report pursuant to section 36 of the Health and Disability Services (Safety) Act 2001 on behalf of Health Audit (NZ) Limited, an auditing agency designated under section 32 of the Act. I confirm that: a) I am a delegated authority of Health Audit (NZ) Limited Yes b) Health Audit (NZ) Limited has in place effective arrangements to avoid or manage any conflicts of interest that may arise Yes c) Health Audit (NZ) Limited has developed the audit summary in this audit report in consultation with the provider Yes d) this audit report has been approved by the lead auditor named above Yes e) the peer reviewer named above has completed the peer review process in accordance with the DAA Handbook Yes f) if this audit was unannounced, no member of the audit team has disclosed the timing of the audit to the provider Not Applicable g) Health Audit (NZ) Limited has provided all the information that is relevant to the audit Yes h) Health Audit (NZ) Limited has finished editing the document. Yes Dated Monday, 8 September 2014

5 Executive Summary of Audit General Overview Wakefield Rest Home provides residential care for up to 22 rest home residents and occupancy on the day of the audit was 17. The facility is currently operated by Wakefield Rest Home Limited. This provisional audit is undertaken to establish the extent to which the existing provider conforms to the requirements of the Health and Disability Services Standards and the District Health Board (DHB) funding contract prior to a change in ownership. This audit also establishes how well prepared the prospective provider is to provide a health and disability service. One of the directors for the prospective provider, Manis Aged Care No 1 Limited, was interviewed during this audit. There are 12 areas identified during this audit that require improvement. The required improvements relate to: collation of the resident and family survey results; development and implementation of corrective action plans to address any areas identified as requiring improvement; completion of adverse event forms; evidence of criminal vetting for staff; the provision of in-service education and completion of competency assessments; management of resident information systems including residents documentation and a resident register; management of residents care plans including completion and evaluation of risk assessments and evaluation of activities care plans; medication management; food service management; and the provision of specialised education for the infection control co-ordinator. Outcome 1.1: Consumer Rights Information regarding the Health and Disability Commissioner's Code of Health and Disability Services Consumers' Rights (the Code of Rights), including the facility's complaints process and the Nationwide Health and Disability Advocacy Service, was accessible and is brought to the attention of residents and their families on admission to the facility. Residents and family members interviewed confirmed that their rights are met during service delivery; that staff are respectful of their needs; communication is appropriate; and they have a clear understanding of their rights and the facility s processes if these are not met. During interview residents and family confirmed that consent forms are provided to them prior to admission and that they are fully informed. They also confirmed that time is provided for any discussions and explanation if required. Residents and family interviewed provided positive feedback on the care provided. The nurse manager is responsible for the management of complaints and a complaints register was maintained. The residents can use the complaints forms, raise issues at the residents' meetings, or they can raise complaints directly with the nurse manager, the registered nurse, or with any member of staff. Outcome 1.2: Organisational Management Wakefield Rest Home Limited is the current governing body and is responsible for the service provided at Wakefield Rest Home. Planning documents reviewed included a business plan with goals as well as a mission statement, values, and philosophy. An organisational chart was also reviewed.

6 Manis Aged Care No 1 Limited is proposing to purchase the facility and assume responsibility for the provision of services from mid October The prospective purchasers were interviewed and advised they currently own another rest home in Ashburton. One of the two directors for Manis Aged Care No1 Limited has worked in the aged care sector for the past 14 years. The prospective purchasers advised the only changes will be a change in ownership and they are not proposing to make any changes to the current staff. They also advised the current nurse manager, who is a registered nurse and who was appointed in January 2014, will remain in place. The nurse manager is responsible for the clinical care of residents and although they had previous aged care experience they were new to rest home management when appointed to their current position. The nurse manager is supported by a part time registered nurse (RN) who started in June 2014 and there is an RN on site seven days a week. The prospective purchaser advised the existing quality and risk management systems have been purchased and they are not proposing to change any of the existing policies and procedures following purchase. They advised they will be reviewing the existing quality and risk management systems and policies and procedures over the next 12 months and updating these as required. The prospective purchaser advised the existing quality plan with quality goals will also be maintained. Improvements are required as although quality improvement data has been collected and collated, the resident/relative survey completed in March 2014 had not been collated, analysed and the results of this survey have not been reported back to residents and family. Improvements are also required to corrective action plans as these have not been consistently documented, implemented and evaluated to measure the effectiveness of the corrective actions. Another area identified as requiring improvement during this audit was completion of adverse event forms as these have not been completed for all known adverse events and staff have not consistently completed all sections on forms they have completed. Staff meetings are held six weekly and there was documented evidence of reporting on numbers of various clinical indicators and quality and risk issues. Copies of meeting minutes were available for staff if they were unable to attend these meetings. There were policies and procedures on human resources management and the validation of current annual practising certificates for registered nurses (RNs) and other health professionals has occurred. Staff files reviewed provided evidence that staff have completed an orientation, have had references obtained and have employment agreements. Improvements are required with this area of service delivery as not all staff files reviewed had evidence of completion of criminal vetting. Annual inservice education days have been provided for staff but there was no education planner available to indicate that ongoing education has been provided for staff on a regular basis and improvements are required. Other areas requiring improvement relating to staff education were also identified as not all staff involved in medicine management have current competency assessments and there was no evidence staff have received wound management education, food safety education, and one of the two registered nurses did not have a current first aid certificate. There was a documented rationale for determining staffing levels and skill mix and the minimum number of staff is provided during the night shift and consists of one care giver on duty. The nurse manager/registered nurse and the registered nurse share the after-hours on call and are available if required. Care staff interviewed report there is adequate staff available and that they are able to get through their work.

7 Resident information is entered into a register in an accurate and timely manner although improvements are required as discharge and transfer dates have not been consistently recorded in the resident register. Improvements were identified with other aspects of documentation management including the use of correction fluid and pencil and recording of the date and time of entry in residents notes. Outcome 1.3: Continuum of Service Delivery Wakefield rest home had a documented entry criteria which was communicated to residents, family and referral agencies. The systems were implemented that evidence each stage of service provision (assessment, planning, provision, evaluation, review and exit) has been developed with resident and/or family input and coordinated to promote continuity of service delivery. There were areas required for improvement around service delivery timeframes. The residents and family interviewed confirm their input into assessments, care planning and evaluation of care and the residents state interventions noted in their care plans were consistent with meeting their needs. A sampling of residents' clinical files validates service delivery to residents. There were areas requiring improvement around documentation of short term care plans and short term care plan interventions. The planned activities were appropriate to the group setting. The residents and family interviewed confirm satisfaction with the activities programme. The residents' files evidence individual activities were provided either within group settings or on one-on-one basis. A visual inspection of the medication area in the facility evidenced an appropriate and secure medicine dispensing system. Appropriate systems were documented and implemented for a resident who self- administers medicines. There were areas requiring improvement around medication management system to comply with respective legislation, regulation and guidelines and staff who administered medications are assessed by a registered nurse as competent. Wakefield rest home had a kitchen and on site staff that provide the food service. The residents' dietary needs are identified, documented and reviewed on a regular basis. There were areas identified as requiring improvement around menu review by a dietitian, adherence to the planned menu by the cook and dating of decanted foods. Outcome 1.4: Safe and Appropriate Environment With one exception, accommodation for residents was provided in single bedrooms and all bedrooms had wash hand basins. Toilets and shower facilities were in close proximity to resident's bedrooms. Residents' rooms were observed to be of varying sizes and adequate personal space was provided in bedrooms. There was a large lounge and dining area available and additional areas for residents to sit were observed throughout the facility. External areas were available for sitting and shading was provided in these areas. An appropriate call bell system was available and security systems were in place.

8 Visual inspection provided evidence of sluice facilities, safe storage of chemicals and equipment, and that protective equipment and clothing was provided and used by staff. Review of documentation provided evidence there were appropriate systems in place to ensure the residents physical environment is safe, and facilities were fit for their purpose. There were policies and procedures for waste management, cleaning and laundry, and emergency management and these were known by staff. All laundry was washed on site and cleaning and laundry systems included appropriate monitoring systems in place to evaluate the effectiveness of these services. There were safe and hygienic storage areas for cleaning equipment, soiled linen and chemicals. Outcome 2: Restraint Minimisation and Safe Practice There were no restraints or enablers used by residents at the facility on audit days. The documentation of policies and procedures demonstrate residents were experiencing services that were least restrictive. The service had processes in place for determining restraint approval and restraint processes. Outcome 3: Infection Prevention and Control There were infection prevention and control (IC) policies and procedures for the prevention and minimisation of infection and cross infection, and contain all requirements in the standard and guide staff in all areas of infection control practice. Infection control was a standard agenda item at the facility meetings. Staff interviewed were familiar with infection control measures at the facility. Surveillance for residents who develop infection was occurring and this was collated monthly and reported to all concerned. There was an area requiring improvement around staff education in infection control to be provided by a suitably qualified person who maintains their knowledge of current practice. Summary of Attainment CI FA PA Negligible PA Low PA Moderate PA High PA Critical Standards Criteria UA Negligible UA Low UA Moderate UA High UA Critical Not Applicable Pending Not Audited Standards Criteria

9 Corrective Action Requests (CAR) Report Code Name Description Attainment Finding Corrective Action Timeframe (Days) HDS(C)S.2008 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. HDS(C)S.2008 Criterion Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers. HDS(C)S.2008 Criterion A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented. HDS(C)S.2008 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 PA Low PA Low PA Moderate PA Moderate The resident/relative satisfaction survey was completed in March 2014 and the completed survey results have not been collated, analysed and the results from this survey have not been reported back to the residents and family members. Internal audits and meeting minutes are reviewed where areas have been identified as requiring improvement but corrective action plans are being consistently documented, implemented, monitored, evaluated and signed off as having been completed. These documents do not consistently identify the person/s responsible for the corrective action and the timeframe for implementation of the corrective action/s. Provide documented evidence that the resident/relative satisfaction survey completed in March 2014 has been collated, analysed, a corrective action plan has been developed to address any improvements identified, and that the results of this analysis are reported to residents and family. Provide documented evidence that: (i) where areas have been identified as requiring improvement corrective action plans are being consistently documented, implemented, monitored, evaluated and signed off as having been completed; and (ii) the person/s responsible for the corrective action and the timeframe for implementation of the corrective action/s are clearly identified

10 Code Name Description Attainment Finding Corrective Action Timeframe (Days) their family/whānau of choice in an open manner. HDS(C)S.2008 Criterion The service provider documents adverse, unplanned, or untoward events including service shortfalls in order to identify opportunities to improve service delivery, and to identify and manage risk. HDS(C)S.2008 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. HDS(C)S.2008 Criterion The appointment of appropriate service providers to safely meet the needs of consumers. HDS(C)S.2008 Criterion A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers. PA Moderate PA Moderate PA Low PA Moderate (i)adverse event forms are not being completed for all adverse events. (ii) Staff are not consistently completing all sections of the accident/incident forms (iii) Neurological observations are not completed for residents following unwitnessed walls and/or any fall with head injury or the potential for head injury. Three of seven staff files reviewed does not have evidence of criminal vetting having been completed. (i) There is no education planner available to indicate education is provided on a regular basis (ii) The two registered nurses and the enrolled nurse do not have current medication competency assessments (see link criterion ). (iii) Five of the eight care staff have had their medication competency assessed by another care giver rather than by one of the two registered nurses (see link criterion ). Provide documented evidence that: (i) all adverse events are being recorded for all adverse events; (ii) that all sections of the accident/incident forms are being completed; and (iii) neurological observations are being completed for residents following unwitnessed walls and/or any fall with head injury or the potential for head injury. Provide confirmation that criminal vetting is undertaken for all staff. Provide documented evidence that: (i) an inservice education plan has been developed and implemented and that inservice education is provided on a regular basis; (ii) the registered nurses and enrolled nurses have their medication competency assessments completed by a registered nurse; (iii) all staff involved in medicine management have their competency assessed by a registered nurse; (iv) the registered nurse has a current first aid certificate; (v) care staff involved in food preparation receive food safety education; and (vi) education relating

11 Code Name Description Attainment Finding Corrective Action Timeframe (Days) HDS(C)S.2008 Standard 1.2.9: Consumer Information Management Systems Consumer information is uniquely identifiable, accurately recorded, current, confidential, and accessible when required. HDS(C)S.2008 Criterion Information is entered into the consumer information management system in an accurate and timely manner, appropriate to the service type and setting. PA Moderate PA Moderate (iv) One of the two registered nurses does not have a current first aid certificate. (v) Care staff assist with food preparation and there is no documented evidence they have received food safety education. (vi) Education has not been provided for the RNs (two), the EN (one) and the care staff relating to wound management. The following issues were identified with documentation during this audit: (i) correction fluid is used in forms and documentation; (ii) pencil is used to make entries in residents activities assessments and activities care plans and in resident meeting minutes; (iii) staff are not consistently recording the date and time of entry in residents progress notes; (iv) staff are not consistently signing and dating all forms including but not limited to risk assessment forms; (v) the resident register does not consistently record the date of discharge/transfer from the facility; and (vi) the resident to wound management is provided. Provide evidence that (i) correction fluid and pencil is not being used in documents (issues i and ii); (iii) the date and time the entry is being made in residents progress notes is recorded; (iv) all forms and risk assessments are signed and dated; (v) the resident register includes the date of discharge/transfer; and (vi) the resident s name is being recorded on all pages of resident s documentation. 60

12 Code Name Description Attainment Finding Corrective Action Timeframe (Days) HDS(C)S.2008 Standard 1.3.3: Service Provision Requirements Consumers receive timely, competent, and appropriate services in order to meet their assessed needs and desired outcome/goals. HDS(C)S.2008 Criterion Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer. HDS(C)S.2008 Standard 1.3.8: Evaluation Consumers' service delivery plans are evaluated in a comprehensive and timely manner. PA Moderate PA Moderate PA Moderate name is not recorded on all pages/parts of resident documentation. Timeframes of service delivery are not always adhered to. Provide evidence timeframes are adhered to. 90

13 HDS(C)S.2008 Criterion Where progress is different from expected, the service responds by initiating changes to the service delivery plan. PA Moderate Short term care plans are not consistently recorded for short term problems and short term care plan interventions are not consistently detailed enough to provide guidance in service delivery for a short term problem. Provide evidence of short term care plans for short term problems and detailed intervention relating to the short term problems. 90 HDS(C)S.2008 Standard : Medicine Management Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines. PA Moderate HDS(C)S.2008 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 i) There are 12 of 17 medication charts that evidence discontinued medicines do not record GP signature and /or date of discontinuation. ii) There is evidence of transcribing of medication in residents clinical files. iii) There is no recorded evidence that the medications arriving at the facility are checked against the residents medication charts. iv) There are four of seventeen medicine charts that evidence the PRN medicines are not signed by GPs and five of seventeen medicine charts that evidence PRN medicines do not always record the indication of use and/ or the frequency of administration. Provide evidence; i) Discontinued medication is dated and signed by GP. ii) Medication transcribing does not occur. iii) There is recorded evidence that the medication arriving at the facility is checked against the resident s medication chart. iv) PRN medicines are signed by GP and record indication of use and frequency of administration. 90 HDS(C)S.2008 Criterion Service providers responsible for medicine management are competent to perform the function for each stage they manage. PA Moderate Not all staff medication competencies have been conducted by a registered nurse and there are staff who administer medicines that do not hold current medication competencies. Provide evidence all staff authorised to administer medicines have been assessed as competent by a registered nurse who has demonstrated competence in medication management. 90

14 HDS(C)S.2008 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 HDS(C)S.2008 Criterion Food, fluid, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group. PA Low i) The menu review last occurred in ii) Menu is altered by the cook to accommodate seasonal variations. iii) Decanted foods are not dated. iv) Residents state there is little variation of food and state some dissatisfaction with food. Provide evidence of current menu review by a dietitian, adherence to the menu by kitchen staff and provide evidence decanted foods are dated. 180 HDS(IPC)S.2008 Standard 3.4: Education The organisation provides relevant education on infection control to all service providers, support staff, and consumers. PA Low HDS(IPC)S.2008 Criterion Infection control education is provided by a suitably qualified person who maintains their knowledge of current practice. PA Low The infection control coordinator has not conducted education in IC. Provide evidence the IC staff education is provided by a suitably qualified person who maintains their knowledge of current IC practice. 180 Continuous Improvement (CI) Report Code Name Description Attainment Finding

15 NZS :2008: Health and Disability Services (Core) Standards Outcome 1.1: Consumer Rights 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, facilitates informed choice, minimises harm, and acknowledges cultural and individual values and beliefs. Standard 1.1.1: Consumer Rights During Service Delivery (HDS(C)S.2008:1.1.1) Consumers receive services in accordance with consumer rights legislation. ARC D1.1c; D3.1a ARHSS D1.1c; D3.1a Staff receive training in the Code of Health and Disability Services Consumers Rights (the Code of Rights) at least annually and staff education records are sighted. Care staff are observed interacting respectfully and communicating appropriately with residents. Staff encourage residents to make choices demonstrating their knowledge of residents rights. Residents (five rest home) and family member (one rest home) are able to verify that services are provided with dignity and respect, privacy is maintained, and individual needs and rights are upheld. These findings are also confirmed during review of the responses in the completed resident and family survey questionnaires that were completed in March Improvements are required as these survey questionnaires have not been collated at the time of this audit (see link criterion ). The questionnaires indicate the majority of the respondents are satisfied with this aspect of service delivery. Interviews with staff (the nurse manager/registered nurse, one registered nurse, three care givers working morning and afternoon shifts, one activities co-ordinator and a physiotherapist) demonstrate an understanding of resident rights. Education records reviewed indicate that staff attend training in resident rights as part of their orientation as well as part of the ongoing education programme (see link criterion ). This education was last provided in July 2014 by the Health and Disability Advocate and was attended by six members of staff. The District Health Board contract requirements are met. Criterion (HDS(C)S.2008: ) Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of their everyday practice.

16 Standard 1.1.2: Consumer Rights During Service Delivery (HDS(C)S.2008:1.1.2) Consumers are informed of their rights. ARC D6.1; D6.2; D16.1b.iii ARHSS D6.1; D6.2; D16.1b.iii One of the two directors of the company proposing to purchase the Wakefield Rest Home (the prospective provider) advises during interview that they have worked in the aged care sector for the last 14 years as a caregiver, an enrolled nurse and as an owner/manager. This director advises they have a thorough knowledge of the consumer rights they must adhere to. The Code of Rights and information on the advocacy service are displayed and are available at the facility. This information is provided as part of the pre-admission and information packs and is included in the resident booklet that is given to all residents and copies of this booklet are sighted in resident bedrooms Residents (five) and family member (one) interviewed confirm they are provided with information regarding the Code and the Nationwide Health and Disability Advocacy Service prior to the resident s admission. The pre-admission and admission information and the Welcome to the Wakefield Rest Home Resident Information packs are reviewed and contain, but is not limited to, information on the Code, advocacy and complaints processes. Residents and family interviewed confirm explanations regarding their rights occur on admission and at any time that they may have a query. The families and residents are informed of the scope of services and any liability for payment for items that are not included in the scope of services. This is included in the service agreement and five admission agreements are reviewed as part of the review of resident s files and all are found to contain this level of information. Residents interviewed confirm they have access to an advocate and one may be appointed if needed. Residents meetings are held two monthly and review of these meeting minutes indicates residents are aware of their rights. A resident / family satisfaction survey was completed in March 2014 and the completed questionnaires reviewed indicates residents and family are aware of their rights. The District Health Board contract requirements are met.

17 Criterion (HDS(C)S.2008: ) Opportunities are provided for explanations, discussion, and clarification about the Code with the consumer, family/whānau of choice where appropriate and/or their legal representative during contact with the service. Criterion (HDS(C)S.2008: ) Information about the Nationwide Health and Disability Advocacy Service is clearly displayed and easily accessible and should be brought to the attention of consumers.

18 Standard 1.1.3: Independence, Personal Privacy, Dignity, And Respect (HDS(C)S.2008:1.1.3) Consumers are treated with respect and receive services in a manner that has regard for their dignity, privacy, and independence. ARC D3.1b; D3.1d; D3.1f; D3.1i; D3.1j; D4.1a; D14.4; E4.1a ARHSS D3.1b; D3.1d; D3.1f; D3.1i; D3.1j; D4.1b; D14.4 Residents are observed being treated with respect by staff during this audit and these findings are confirmed during interviews of residents and a family member and during review of the 12 completed satisfaction survey questionnaires residents and family completed in March Staff receive training on abuse / neglect as part of the annual in-service education day that was last provided in August Staff are observed knocking before entering residents' rooms and keeping doors closed while attending to residents. Care staff demonstrate an awareness of residents rights and the maintenance of professional boundaries. With one exception, all bedrooms provide single accommodation. The one double bedroom has adequate screening and is currently being used by one resident. Activities in the community are encouraged and the nurse manager advises during interview that two or three residents attend community events independently. Church services are held on site as part of the activities programme. Values, beliefs and cultural aspects of care are recorded in residents clinical files reviewed (five rest home). The District Health Board contract requirements are met. Criterion (HDS(C)S.2008: ) The service respects the physical, visual, auditory, and personal privacy of the consumer and their belongings at all times.

19 Criterion (HDS(C)S.2008: ) Consumers receive services that are responsive to the needs, values, and beliefs of the cultural, religious, social, and/or ethnic group with which each consumer identifies. Criterion (HDS(C)S.2008: ) Services are provided in a manner that maximises each consumer's independence and reflects the wishes of the consumer. Criterion (HDS(C)S.2008: ) Consumers are kept safe and are not subjected to, or at risk of, abuse and/or neglect.

20 Standard 1.1.4: Recognition Of Māori Values And Beliefs (HDS(C)S.2008:1.1.4) 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. ARC A3.1; A3.2; D20.1i ARHSS A3.1; A3.2; D20.1i The organisation has a Māori Health Plan that includes the three principals of the Treaty of Waitangi: Partnership, Participation and Protection. The Māori Health Plan describes that the holistic view of Māori health is to be incorporated into the delivery of services (whanau, Hinengaro, Tinana and Wairau). There are currently no residents in the facility that identify as Māori. A cultural assessment is completed as part of the care plan for all residents and is reviewed on the resident s files reviewed. Access to Māori support and advocacy services is available if required via a kaumatua from a marae in Nelson as well as from the local district health board. Family are able to be involved in the care of their family members. Care staff interviewed confirm an understanding of cultural safety in relation to care and that processes are in place to ensure that if there are residents who identify as Māori, that they have access to appropriate services. Cultural safety education was last provided as part of the inservice education day that was last provided in August The District Health Board contract requirements are met. Criterion (HDS(C)S.2008: ) Māori consumers have access to appropriate services, and barriers to access within the control of the organisation are identified and eliminated.

21 Criterion (HDS(C)S.2008: ) The organisation plans to ensure Māori receive services commensurate with their needs. Criterion (HDS(C)S.2008: ) The importance of whānau and their involvement with Māori consumers is recognised and supported by service providers.

22 Standard 1.1.6: Recognition And Respect Of The Individual's Culture, Values, And Beliefs (HDS(C)S.2008:1.1.6) Consumers receive culturally safe services which recognise and respect their ethnic, cultural, spiritual values, and beliefs. ARC D3.1g; D4.1c ARHSS D3.1g; D4.1d Documentation reviewed during this audit provides evidence that appropriate culturally safe practices are implemented and are being maintained, including respect for residents' cultural and spiritual values and beliefs. Documentation reviewed lists the details on how to access appropriate expertise including cultural specialists, and interpreters. Residents' files reviewed demonstrate that admission documentation identifies the ethnicity, cultural and spiritual requirements for the residents as well as family/whanau contact details. All residents have a cultural assessment completed as part of the care planning process. Residents interviewed confirm their culture, values and beliefs are being respected, and their spiritual needs are met. These findings are supported during review of the completed questionnaires for the resident/relative satisfaction survey completed in March Church services are held on site two weekly as part of the activities programme and some residents go out to attend church services with the support of family and friends. Care staff interviewed confirm an understanding of cultural safety in relation to care and that processes are in place to ensure residents have access to appropriate services to ensure their cultural and spiritual values and beliefs are respected. The District Health Board contract requirements are met. Criterion (HDS(C)S.2008: ) The consumer and when appropriate and requested by the consumer the family/whānau of choice or other representatives, are consulted on their individual values and beliefs.

23 Standard 1.1.7: Discrimination (HDS(C)S.2008:1.1.7) Consumers are free from any discrimination, coercion, harassment, sexual, financial, or other exploitation. ARHSS D16.5e There are policies and procedures in place that outline the safeguards to protect residents from all forms of abuse, including discrimination, coercion, harassment, and exploitation, along with actions to be taken if there is inappropriate or unlawful conduct. Policies reviewed include complaints policies and procedures and a staff files reviewed (seven) include copies of house rules that all staff are required to adhere to. These documents also address any conflict of interest issues including the accepting of gifts and personal transactions with residents and are reviewed. Expected staff practice is also outlined in job descriptions and employment contracts, which are reviewed on seven staff files. During interview the administrator describes the process for managing residents comfort account funds. A review of the accident/incident reporting system, complaints register and interview of the nurse manager indicates there has been one unsubstantiated allegation made against a member of staff alleging unacceptable behaviour. Residents and family interviewed report that staff maintain appropriate professional boundaries. Care staff interviewed demonstrate an awareness of the importance of maintaining boundaries and processes they are required to adhere to. Criterion (HDS(C)S.2008: ) Service providers maintain professional boundaries and refrain from acts or behaviours which could benefit the provider at the expense or well-being of the consumer.

24 Standard 1.1.8: Good Practice (HDS(C)S.2008:1.1.8) Consumers receive services of an appropriate standard. ARC A1.7b; A2.2; D1.3; D17.2; D17.7c ARHSS A2.2; D1.3; D17.2; D17.10c There are established professional networks which support an understanding of appropriate practice standards. Referrals are made to a variety of specialist staff from the local district health board. Clinical service delivery is guided by a range of policies and procedures including but not limited to wound management, continence management, pressure area risk management and pain management. Copies of RN Care Guides for Residential Aged Care, which are based on Waitemata District Health Board resources, are available on site. Access to education by specialist educators is provided although limited use has been made of this resource and improvements are required (see link criterion ). Staff interviewed confirm understanding of professional boundaries and practice. The District Health Board contract requirements are met. Criterion (HDS(C)S.2008: ) The service provides an environment that encourages good practice, which should include evidence-based practice.

25 Standard 1.1.9: Communication (HDS(C)S.2008:1.1.9) Service providers communicate effectively with consumers and provide an environment conducive to effective communication. ARC A13.1; A13.2; A14.1; D11.3; D12.1; D12.3a; D12.4; D12.5; D16.1b.ii; D16.4b; D16.5e.iii; D20.3 ARHSS A13.1; A13.2; A14.1; D11.3; D12.1; D12.3a; D12.4; D12.5; D16.1bii; D16.4b; D16.53i.i.3.iii; D20.3 An open disclosure policy and procedures are in place to ensure staff maintain open, transparent communication with residents and their families and are reviewed. Residents' files reviewed (five rest home) provide evidence that communication with family members is being documented in residents' records. There is evidence of communication with the GP and family following adverse events, which is recorded on the accident/incident forms, on family communication sheets and in the individual resident's files. Residents and family interviewed confirm that staff communicate well with them. Residents interviewed confirm that they are aware of the staff that are responsible for their care. The nurse manager advises access to interpreter services is available if required via the district health board if required. They also advise there are currently no residents who require 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. Five admission agreements are reviewed and this is clearly communicated in each agreement. The District Health Board contract requirements are met. Criterion (HDS(C)S.2008: ) Consumers have a right to full and frank information and open disclosure from service providers.

26 Criterion (HDS(C)S.2008: ) Wherever necessary and reasonably practicable, interpreter services are provided. Standard : Informed Consent (HDS(C)S.2008:1.1.10) Consumers and where appropriate their family/whānau of choice are provided with the information they need to make informed choices and give informed consent. ARC D3.1d; D11.3; D12.2; D13.1 ARHSS D3.1d; D11.3; D12.2; D13.1 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 agreements. The nurse manager, who is a registered nurse, as well as the registered nurse (RN) who works part time report informed consent is discussed and is recorded at the time the resident is admitted to the facility. Residents/family are provided with various consent forms on admission for completion as appropriate and are reviewed on five resident s 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 are reviewed on resident s files. Staff interviewed (three care givers, one RN, one physiotherapist and the nurse manager) demonstrate a good understanding of informed consent processes. Residents (five rest home) and family (one rest home) interviewed confirm they have been made aware of and understand the principles of informed consent, and confirm informed consent information has been provided to them and their choices and decisions are acted on. Residents' files reviewed demonstrate written and verbal discussions on informed consent have occurred and residents' files evidence signed informed consent forms. Residents' admission agreements are signed. Staff education on the Code of Rights, which included advocacy and consent, was provided in July 2014 by the advocate from the Nationwide Advocacy Services. The District Health Board contract requirements are met.

27 Criterion (HDS(C)S.2008: ) Service providers demonstrate their ability to provide the information that consumers need to have, to be actively involved in their recovery, care, treatment, and support as well as for decision-making. Criterion (HDS(C)S.2008: ) The service is able to demonstrate that written consent is obtained where required. Criterion (HDS(C)S.2008: ) Advance directives that are made available to service providers are acted on where valid.

28 Standard : Advocacy And Support (HDS(C)S.2008:1.1.11) Service providers recognise and facilitate the right of consumers to advocacy/support persons of their choice. ARC D4.1d; D4.1e ARHSS D4.1e; D4.1f There are appropriate policies regarding advocacy/support services in place that specify advocacy processes and how to access independent advocates and these are reviewed. Care staff interviewed demonstrate an understanding of how residents can access advocacy/support persons. Care staff interviewed confirm they have attended education on the Code of Right, advocacy, and complaint management. Residents and family interviewed confirm that advocacy support is available to them if required, and that information on how to access the Health and Disability Advocate is included in the information package they receive on admission. Visual inspection provides evidence the nationwide advocate details are displayed along with advocacy information brochures. Admission / pre-admission information is reviewed and provides evidence advocacy, complaints and Code of Rights information is included. The District Health Board contract requirements are met. Criterion (HDS(C)S.2008: ) Consumers are informed of their rights to an independent advocate, how to access them, and their right to have a support person/s of their choice present.

29 Standard : Links With Family/Whānau And Other Community Resources (HDS(C)S.2008:1.1.12) Consumers are able to maintain links with their family/whānau and their community. ARC D3.1h; D3.1e ARHSS D3.1h; D3.1e; D16.5f There are documented visitors' policy and guidelines available to ensure resident safety and well-being is not compromised by visitors to the service (for example, visitors are required to sign in and out via registers). The activities programme includes access to community groups and there are systems in place to ensure residents remain aware of current affairs. Residents and family members interviewed confirm they can have access to visitors of their choice, and confirm they are supported to access services within the community. Access to community support/interest groups is facilitated for residents as appropriate and a mobility van is available to take residents on community visits. Some residents go out independently on a regular basis. Residents' files reviewed demonstrate that progress notes and the content of care plans (see link ) includes regular outings and appointments (records sighted). The District Health Board contract requirements are met. Criterion (HDS(C)S.2008: ) Consumers have access to visitors of their choice.

30 Criterion (HDS(C)S.2008: ) Consumers are supported to access services within the community when appropriate. Standard : Complaints Management (HDS(C)S.2008:1.1.13) The right of the consumer to make a complaint is understood, respected, and upheld. ARC D6.2; D13.3h; E4.1biii.3 ARHSS D6.2; D13.3g The nurse manager is responsible for complaints and there are appropriate systems in place to manage the complaints processes. A complaints register is maintained that includes four complaints (verbal) for 2014 and none for 2013 and the complaints register is reviewed. Three of the four complaints received for 2014 relate to the poor TV reception and this issue has now been addressed. The nurse manager advises there have been no complaint investigations by the Ministry of Health, Health and Disability Commissioner, District Health Board (DHB), Accident Compensation Corporation (ACC) or Coroner since the previous audit at this facility. There has been one complaint made to the Police in April 2014 and documentation reviewed indicates this complaint was closed off by the Police in May This complaint was also notified to the Ministry of Health in May 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 (five rest home) and family (one rest home) interviewed demonstrate an understanding and awareness of these processes. Resident meetings are held two monthly and residents are able to raise any issues they have during these meetings and this is confirmed during interview of residents and review of meeting minutes. A visual inspection of the facility provides evidence that the complaint process is readily accessible and/or displayed. Review of staff/quality meeting minutes and the nurse manager s monthly reports to the director provides evidence of reporting of complaints to the governing body and staff. Care staff interviewed confirm this information is reported to them via their staff/quality meetings. The District Health Board contract requirements are met.