Manis Aged Care Limited Introduction This report records the results of a Surveillance Audit of a provider of aged residential care services against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008). The audit has been conducted by Health and Disability Auditing New Zealand Limited, an auditing agency designated under section 32 of the Health and Disability Services (Safety) Act 2001, for submission to the Ministry of Health. The abbreviations used in this report are the same as those specified in section 10 of the Health and Disability Services (General) Standards (NZS8134.0:2008). You can view a full copy of the standards on the Ministry of Health s website by clicking here. The specifics of this audit included: Legal entity: Premises audited: Services audited: Manis Aged Care Limited Cameron Courts Resthome Rest home care (excluding dementia care) Dates of audit: Start date: 26 September 2016 End date: 26 September 2016 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: 17 Manis Aged Care Limited Date of Audit: 26 September 2016 Page 1 of 17
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 Manis Aged Care Limited Date of Audit: 26 September 2016 Page 2 of 17
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 Cameron Courts provides rest home level of care for up to 31 residents. On the day of the audit, there were 17 rest home residents. There are two owners, one of whom was the facility manager, and is an enrolled nurse. The owners are supported by a clinical manager (registered nurse), a registered nurse and care staff. A temporary manager (external consultant) was appointed by the DHB for three months while a new facility manager was being sought. The role has now ceased. This surveillance audit was conducted against the Health and Disability Standards and the contract with the district health board. The audit process included the review of policies and procedures, the review of residents and staff files, observations, and interviews with residents, family, and staff. The service has addressed six of seven findings from the previous audit around corrective actions, use of correction fluid, timeframes for completion of care planning, conducting assessments, interventions and eliminating trip hazards. Further improvement is required in relation to care planning. This audit identified that improvements are required around medication documentation. Manis Aged Care Limited Date of Audit: 26 September 2016 Page 3 of 17
Consumer rights Includes 13 standards that support an outcome where consumers receive safe services of an appropriate standard that comply with consumer rights legislation. Services are provided in a manner that is respectful of consumer rights, facilities, informed choice, minimises harm and acknowledges cultural and individual values and beliefs. Standards applicable to this service fully attained. Communication with families is recorded. Complaints processes are implemented and managed in line with the Code. 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. Standards applicable to this service fully attained. Cameron has two owners, one of whom is an enrolled nurse (EN) and is in the role of facility manager. The manager was absent on the day of audit. A temporary manager has filled the role of manager prior to the current clinical manager being appointed. The owner/manager, clinical manager and registered nurse (RN) are responsible for the implementation of the quality and risk management programme. The service has policies and procedures in place to support care. Quality activities are conducted. There are human resource policies including recruitment, job descriptions, selection, orientation and staff training and development. The service has an orientation programme that provides new staff with relevant information for safe work practice. There is an education programme covering relevant aspects of care and external training is supported. The staffing policy aligns with contractual requirements and includes appropriate skill mixes to provide safe delivery of care. Manis Aged Care Limited Date of Audit: 26 September 2016 Page 4 of 17
Continuum of service delivery Includes 13 standards that support an outcome where consumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent with current legislation. Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk. Assessments, care plans and reviews are completed by a registered nurse within the required timeframes. Each resident has access to an individual and group activities programme. The group programme is varied and interesting. Medication is stored appropriately in line with legislation and guidelines. 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 provided. Residents and relatives interviewed were complimentary about the food service. Safe and appropriate environment Includes 8 standards that support an outcome where services are provided in a clean, safe environment that is appropriate to the age/needs of the consumer, ensure physical privacy is maintained, has adequate space and amenities to facilitate independence, is in a setting appropriate to the consumer group and meets the needs of people with disabilities. Standards applicable to this service fully attained. The building has a current warrant of fitness. Manis Aged Care Limited Date of Audit: 26 September 2016 Page 5 of 17
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. Cameron Courts has restraint minimisation and safe practice policies and procedures in place. Staff receive training in restraint minimisation and challenging behaviour management. There were no residents requiring the use of a restraint or an enabler. Infection prevention and control Includes 6 standards that support an outcome which minimises the risk of infection to consumers, service providers and visitors. Infection control policies and procedures are practical, safe and appropriate for the type of service provided and reflect current accepted good practice and legislative requirements. The organisation provides relevant education on infection control to all service providers and consumers. Surveillance for infection is carried out as specified in the infection control programme. Standards applicable to this service fully attained. The infection control programme was appropriate for the size and complexity of the service. Information is obtained through surveillance to determine infection control activities. Manis Aged Care Limited Date of Audit: 26 September 2016 Page 6 of 17
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 0 17 0 0 2 0 0 Criteria 0 42 0 0 2 0 0 Attainment Rating Unattained Negligible Risk (UA Negligible) Unattained Low Risk (UA Low) Unattained Moderate Risk (UA Moderate) Unattained High Risk (UA High) Unattained Critical Risk (UA Critical) Standards 0 0 0 0 0 Criteria 0 0 0 0 0 Manis Aged Care Limited Date of Audit: 26 September 2016 Page 7 of 17
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 1.1.13: Complaints Management The right of the consumer to make a complaint is understood, respected, and upheld. Standard 1.1.9: Communication Service providers communicate effectively with consumers and provide an environment Attainment Rating Audit Evidence There is a complaints policy to guide practice, which aligns with Right 10 of the Code. The facility manager leads the investigation of concerns and complaints. Complaints forms are visible for relatives/residents. A complaints procedure is provided to residents within the information pack at entry. The service has responded appropriately to two internal complaints received in 2016, including response letters, staff meetings and improvements made to service. The complaints register is up to date. There is a policy to guide staff on the process around open disclosure, and for residents who do not have any family to notify. The clinical manager confirms family are kept informed. The family member interviewed stated they are notified promptly of any incidents/accidents. Resident meetings encourage open discussion around the services provided (meeting minutes sighted). The recent changes in registered nursing staff and the appointment of a temporary manager was communicated to residents, family and staff. Incident and accident reports sampled and associated resident files reviewed, evidence that family are notified. Residents with English as a second language have their communication needs met via staff, family or through access to an interpreter service as required. Manis Aged Care Limited Date of Audit: 26 September 2016 Page 8 of 17
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. Cameron Courts rest home provides care for up to 31 rest home level residents. On the day of audit, there were 17 residents including one respite resident. All permanent residents are under the aged care contract. The service has a business plan for 2015 2018, which includes business goals, which are reviewed annually. The strategic plan identifies the purpose, values and scope of the business. The service has quality goals, which are reviewed at the staff meetings. The owners have owned Cameron Courts for the past six years. The owners contract an external consultant (registered nurse) to provide support and education for staff. A temporary manager (external consultant) was contracted by the DHB from June to August while the service advertised for a new facility manager/clinical manager. There has been a turnover of two clinical managers during 2016. The current clinical manager started employment on 1 August 2016 and the new registered nurse commenced employment in July 2016. The owner/facility manager attends the service approximately two times per month. 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. Cameron Courts is implementing a quality and risk management system. The quality programme for 2016 is reviewed at the quality meetings. The goals are set and reviewed each year. There are policies and procedures implemented to provide assurance that the service is meeting accepted good practice and adhering to relevant standards. Staff confirmed they are made aware of any new/reviewed policies. The service is supported by an external quality consultant who provides site visits, in-service education and policy updates. Three monthly combined quality and staff meeting minutes sighted evidence staff discussion around accident/incident data, health and safety, infection control, audit outcomes, concerns and survey feedback. Monthly data collation occurs with analysis conducted. The clinical manager, healthcare assistants (interviewed) were aware of quality data results and trends. Quality activities are conducted including an internal audit schedule, collation and analysis of incidents and accidents and annual resident and family surveys. Corrective actions have been developed for internal audits that have aspects of non-compliance and these have been completed. Annual resident and relative surveys are conducted. The resident and family survey conducted in May 2016 has been collated and reviewed for identification of areas requiring improvement. The service has addressed the previous audit finding. An internal audit programme covers all aspects of the service and aligns with the requirements of the Health and Disability Services (Safety) Act 2001. A summary of internal audit outcomes is provided to the quality and staff Manis Aged Care Limited Date of Audit: 26 September 2016 Page 9 of 17
meetings for discussion. There is an implemented health and safety, and risk management system in place including policies to guide practice. There is a current hazard register. Staff confirm they are kept informed on health and safety matters at meetings and on the staff notice board. Fall prevention strategies are in place that include the analysis of falls incidents and the identification of interventions on a case by case basis to minimise future falls. 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 A sample of 11 accident/incident forms for the months of July and August were reviewed with associated resident files. There has been RN notification and clinical assessment completed within a timely manner as documented on the reporting forms. Accidents/incidents were recorded in the resident progress notes. There is documented evidence the family had been notified promptly of accidents/incidents. The service collects incident and accident data and reports aggregated figures to the staff meeting. Staff interviewed confirm incident and accident data is discussed at the staff meeting and information is made available. Discussions with the clinical manager, confirms an awareness of the requirement to notify relevant authorities in relation to essential notifications. There are human resources policies to support recruitment practices. Five staff files sampled (one clinical manager, one registered nurse, two health care assistants, and one cook) contained all relevant employment documentation. Current practising certificates were sighted for the registered nurses and allied health professionals. The service has an orientation programme in place that provides new staff with relevant information for safe work practice. Staff interviewed believed that new staff were adequately orientated to the service on employment. Annual appraisals have been conducted for all staff employed over 12 months. An education planner in place covers compulsory education requirements over a two-year period. Regular inservice education has been provided for staff. Both the clinical manager and the registered nurse have completed the InterRAI training. Staff complete competencies relevant to their role. Manis Aged Care Limited Date of Audit: 26 September 2016 Page 10 of 17
legislation. 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. Standard 1.3.12: Medicine Management Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice PA Moderate The service has a documented rationale for determining staffing levels and skill mixes for safe service delivery. A roster provides sufficient and appropriate coverage for the effective delivery of care and support. The rosters have been adjusted in line with reduced resident occupancy. The registered nurses work over seven days a week and provide after hours on-call cover. The owner/manager attends the facility twice per month and is available via phone and email. The residents and family interviewed inform there are sufficient staff on duty. The resident files are appropriate to the service type. All resident records containing personal information is kept confidential. Entries in progress notes were legible, dated and signed by the relevant carer or registered nurse including designation. There was no evidence of the use of correction fluid in the documentation reviewed. The service has addressed this previous finding. The medication management policies and procedures comply with medication legislation and guidelines. Medicines are appropriately stored in accordance with relevant guidelines and legislation. Medication administration practice complies with the medication management policy for the medication round sighted. Medication prescribed was not consistently signed for as given, as prescribed in the sample of ten medication charts reviewed. The clinical manager, registered nurse and medication competent healthcare assistants administer medicines to the residents. Staff who administer medication have been assessed as competent. The facility uses a blister pack medication management system for the packaging of all tablets. The clinical manager and registered nurse reconcile the delivery and this is documented. Medication charts are written by medical practitioners and there was evidence of three monthly reviews by the GP. Medications were prescribed, however were not always charted in line with guidelines including indications for use for as needed medications. There is one resident who self-administers medication. Manis Aged Care Limited Date of Audit: 26 September 2016 Page 11 of 17
guidelines. Standard 1.3.13: 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. Standard 1.3.4: Assessment Consumers' needs, support requirements, and preferences are gathered and recorded in a timely manner. The food is prepared and cooked onsite in the large kitchen. The kitchen is located adjacent to the dining room. A tray service is provided to residents who are unwell or prefer not to attend the dining room. Food service manuals are in place to guide staff. A resident dietary profile is developed for each resident on admission and is provided to the kitchen staff. The kitchen is able to meet the needs of residents who require special diets and the cooks work closely with the registered nurses. Kitchen staff have completed food safety training. The cooks follow a rotating menu, which has recently been reviewed by a dietitian. Recommendations made by the dietitian regarding the menu have been addressed and the draft menus have been returned to the dietitian for approval. The temperatures of refrigerators, freezers and cooked foods are monitored and recorded daily. There is special equipment available for residents if required. All food is stored appropriately. Residents interviewed were very happy with the quality and variety of food served. InterRAI assessments have been completed for four long-term residents (one resident file was for a respite resident). Additional paper-based assessments included (but not limited to) dietary needs, continence, falls risk, pressure risk and pain. Personal needs information is gathered during admission, which formed the basis of resident goals and objectives. Assessments are reviewed at least six monthly. Appropriate risk assessments had been completed for individual resident issues. The respite resident had an initial nursing assessment and plan in place. The service has addressed the previous audit findings relating to completion of InterRAI assessments on admission. Clinical risk assessments were completed accurately to reflect the degree of risk and interventions to manage risk were reflected in care plans. Standard 1.3.5: Planning Consumers' service delivery plans are consumer focused, integrated, and promote continuity of service delivery. Standard 1.3.6: Service PA Moderate The previous audit identified that not all care plans contained sufficient detail to direct care delivery. Not all care plans reviewed included all care requirements. This previous finding remains. The goals of the care plan were resident centred with measurable goals. Short-term care plans were in use for changes in health status and were evaluated on a regular basis and signed off as resolved or transferred to the long-term care plan. There was evidence of service integration with documented input from a range of specialist care professionals. Healthcare assistants follow the care plans and report progress against the care plan each shift. If external nursing or allied health advice is required, the clinical manager or RN will initiate a referral. Staff have access to sufficient Manis Aged Care Limited Date of Audit: 26 September 2016 Page 12 of 17
Delivery/Interventions Consumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes. medical supplies including 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. Monitoring forms are in place for food and fluid intake, weight monitoring and pain assessment. Progress notes reviewed for five residents, evidence that there has been timely and appropriate follow up by a registered nurse for residents with changes in health condition. This included residents who had fallen, and residents who were unwell. The service has addressed this previous audit finding. Wound documentation is available and includes assessments, management plans, progress and evaluations. There was one resident with a wound, a skin tear, a wound assessment, treatment and evaluation form was evidenced completed by an RN. The clinical manager and registered nurse have attended wound care training. 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. Standard 1.3.8: Evaluation Consumers' service delivery plans are evaluated in a comprehensive and timely manner. Standard 1.4.2: Facility Specifications Consumers are provided with an An activities coordinator delivers the activities programme for all residents. The staff member was not available for interview on the day of audit. An individual activities assessment is completed for each resident on admission and from this information, a diversional therapy plan is developed. The activities programme reflects the residents cognitive and physical abilities. Activities are provided for each morning and afternoon from Monday to Friday by the activities coordinator, with healthcare assistants delivering the programme at weekends. The programme is varied and includes involvement in events and festivals happening in the local community. The service has a van that is used for outings. The residents interviewed expressed satisfaction with the programme. The residents reported they are able to provide feedback on the programme verbally to the activities coordinator and at residents meetings. All initial care plans are evaluated by the registered nurses within three weeks of admission. The long-term care plan is reviewed at least six monthly or earlier if there is a change in health status. However, not all care plans had been updated to reflect the resident s needs (link 1.3.5.2). Reviews document progress toward goals. There is at least a three monthly review by the GP. Care plan reviews are signed by an RN. Short-term care plans are evaluated and resolved or added to the long-term care plan if the problem is ongoing as sighted in resident files sampled. The building holds a current warrant of fitness, which expires on 1 October 2016. The carpet floor covering in two hallways in the north end of the facility have been replaced. The service has eliminated the trip hazard for residents and staff in these areas and has addressed this previous audit finding. Manis Aged Care Limited Date of Audit: 26 September 2016 Page 13 of 17
appropriate, accessible physical environment and facilities that are fit for their purpose. Standard 3.5: Surveillance Surveillance for infection is carried out in accordance with agreed objectives, priorities, and methods that have been specified in the infection control programme. Standard 2.1.1: Restraint minimisation Services demonstrate that the use of restraint is actively minimised. The surveillance policy describes the purpose and methodology for the surveillance of infections. Systems in place are appropriate to the size and complexity of the facility. Individual infection report forms were completed for all infections and kept as part of the resident files. Infections were included on a register and a monthly report was completed by the infection control coordinator (registered nurse). Monthly data has been reported to the combined infection control and staff meetings. The infection control coordinator uses the information obtained through surveillance to determine infection control activities, resources, and education needs within the facility. There is close liaison with the GPs that advise and provide feedback/information to the service. A recent outbreak was appropriately managed with notification to Public Health. The clinical manager is also responsible for restraint review and use should this occur. There were no residents on restraint or enablers on the day of the audit. There is a documented definition of restraint and enablers, which is congruent with the definition in NZS 8134.0. The restraint policy includes comprehensive restraint procedures. Enablers are voluntary. The service has no residents with enablers or restraint. Staff are trained in restraint minimisation and the management of challenging behaviours. Manis Aged Care Limited Date of Audit: 26 September 2016 Page 14 of 17
Specific results for criterion where corrective actions are required Where a standard is rated partially attained (PA) or unattained (UA) specific corrective actions are recorded under the relevant criteria for the standard. The following table contains the criterion where corrective actions have been recorded. Criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1: Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of their everyday practice relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights. If there is a message no data to display instead of a table, then no corrective actions were required as a result of this audit. Criterion with desired outcome Attainment Rating Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.3.12.1 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 On a review of medication signing sheets, eight of ten evidenced full completion of forms and were signed as being given as prescribed. Seven of ten medication charts were charted correctly and documented the date of medication prescribed and included indication for use of as needed medication. (i) Three of ten medication charts did not document the indication for use of as needed medications prescribed. (ii) The commencement date of prescribed medication was not documented on three of ten medication charts. (iii) Medication was not evidenced to have been given or signed-for as prescribed, in two of ten medication signing sheets reviewed. (i) Ensure as needed medications include the reason for prescribed use. (ii) Ensure medications are charted correctly and include date of commencement. (iii) Ensure all medication is signed for at the time of Manis Aged Care Limited Date of Audit: 26 September 2016 Page 15 of 17
administration. 30 days Criterion 1.3.5.2 Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process. PA Moderate Three of five resident files sampled demonstrated that care plans were comprehensive and demonstrate service integration and input from allied health. Care plans for two of five residents did not document the interventions and support required to meet all current needs. (i) One resident with a catheter had insufficient interventions to guide staff in the management of the catheter. (ii) One resident with weight loss had not had the care plan updated to reflect dietitian recommendations. (i-ii) Ensure care plans are updated to reflect the resident s current needs. 60 days Manis Aged Care Limited Date of Audit: 26 September 2016 Page 16 of 17
Specific results for criterion where a continuous improvement has been recorded As well as whole standards, individual criterion within a standard can also be rated as having a continuous improvement. A continuous improvement means that the provider can demonstrate achievement beyond the level required for full attainment. The following table contains the criterion where the provider has been rated as having made corrective actions have been recorded. As above, criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1 relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights If, instead of a table, these is a message no data to display then no continuous improvements were recorded as part of this of this audit. No data to display End of the report. Manis Aged Care Limited Date of Audit: 26 September 2016 Page 17 of 17