Social Services Council of the Diocese of Christchurch Incorporated - Fitzgerald
Date of on-site Designated Auditing Agency verification of progress towards meeting partially attained criteria found at last audit : 22 November 2010 Three-monthly quality and monthly unit manager meetings are held which include an analysis of quality data with corrective actions identified. Issues are also discussed at weekly management meetings. Police and referee/reference checks are completed for all new employees. The orientation programme is fully completed for all new employees. Dry and fresh foods are all within the use by date.
Water temperature audits have been implemented and meet the requirements.
All night store heaters that could not be adjusted have been removed and replaced with ceiling panel heaters.
The initial care plan is written on admission and the long term care plan is written within three weeks after admission. A comprehensive assessment of each resident is
completed and held in clinical files.
Monthly in-service education is provided for all staff involved in administering medication. The emphasis is on accurate documentation of medication administration and signing for the same. All medication errors are reported on an incident form and are collated and reviewed monthly by the facility manager. All medication sheets sighted were signed correctly.
Meal service was attended in the hospital and dementia wing. Assistance was provided to those who required it on a one-to-one basis.
Date of audit: 29-Apr-10
The following summary has been accepted by the Ministry of Health as being an accurate reflection of the certification audit conducted against the Health and Disability Services Standards – NZS8134.1:2008;NZS8134.2:2008 &
NZS8134.3:2008 on the audit date(s) specified.
General overview
Fitzgerald Complex is part of the Anglican Aged Care Group. A new Clinical Manager has been appointed to the facility and is due to commence in June 2010.The Anglican Group will continue to use the Selwyn Foundation documentation and audit systems until the end of May, after which a consultant has been engaged to assist in the management of the quality programme.
Due to the changes in management and turnover of registered nurses, along with some complaints received, the DHB has conducted a number of spot audits over the past year.
This has resulted in a number of improvements including improvements to the garden areas in the dementia unit, repainting, and the appointment of a registered nurse in the rest home. Improvements have also been made in the documentation and more consistency in service delivery. A core of committed and experienced staff continue to improve all aspects of the service.
Consumer Rights
Consumer rights information is provided at the time of admission and is displayed and available. Service providers demonstrate an understanding of consumers' rights. Consumers are able to have their personal possessions in their rooms, and this is included in their code of rights. Some double rooms with curtains to provide privacy are in place. Care provision is in line with current accepted good practice. The clinical coordinator oversees all aspects of care delivery. Informed consent information is
provided at the time of admission and appropriate consents are obtained and completed. These are held in clinical files and reviewed appropriately. The residents code of rights includes consumer access to visitors and privacy for treatment and conversations. Consumer confirmation was obtained. There is a documented complaints process in place and suggestion boxes were viewed around the facility. The complaints analysis process currently includes items which would be better included as incidents and incorrectly identifies some complainants as staff. The complaints process has the ability to further identify issues/trends but this has not happened.
Organisational Management
Organisational objectives for both the Selwyn Foundation and Anglican Aged Care are documented. On the day of the audit it was the Manager's last day of employment at the Fitzgerald Complex, and a new Clinical Manager for the facility has been appointed to commence in June. As an interim the Director (a registered nurse) will stand in as the Manager. The facility is currently benchmarked against other Selwyn Foundation facilities. Regular spot audits by the District Health Board have been conducted and progress has been made against corrective actions.
Quality and risk management planning is based on Selwyn Foundation documentation, and documented policies and procedures reflect good practice. Quality information is gathered and entered electronically for analysis, and an extensive analysis is completed by the Selwyn Foundation. There is no formal quality meeting system which considers on a regular basis the extensive quality data received. A quality audit programme is in place and adverse events are documented and analysed. There is little evidence of the quality information being fully considered at quality management meetings for corrective
actions. Consumers confirm being kept informed of any adverse events relevant to them.
Extensive human resource management documentation is in place but not fully implemented in relation to orientation and recruitment procedures. There is a mandatory education plan in place with low compliance but additional education has been provided for identified issues. Staff levels reflect the current rosters and are in line with the organisations policies and procedures. Consumer records are consistently accurate, current and accessible. Confidentiality is maintained.
Continuum of Service Delivery
Entry to the service is based on residents meeting the entry criteria. This is managed in an equitable, timely and respectful manner. The standard of care is in line with current accepted good practice. Residents and relatives interviewed all expressed satisfaction with the service. They stated staff were caring, patient and respectful.
On admission all residents undergo a comprehensive assessment to identify their needs. This includes the person's own goals. Care plans are reviewed at regular intervals and whenever the needs of the resident changes. A multidisciplinary approach is taken and residents and their support people of choice are invited to attend review meetings. Those residents wishing to access other health and disability services are assisted to do this. A variety of activities are provided which include individual and group experiences. There are opportunities to further develop the activities in the dementia unit.
Policies and procedures are in place for the management of medicines. The service is working to improve implementation of these.
Food services are contracted, and the two main meals of the day are prepared at another Anglican Aged Care facility and transported in hot boxes. A choice of main meals is provided and information on consumer choices, likes, dislikes is communicated daily to the kitchen. The temperature of meals is taken on arrival to the facility and records were viewed to be above requirements. A mainly positive response is expressed through consumer satisfaction surveys and on the day of the audit in regard to the meals. Individual clinical files contain a dietary profile and identify nutritional
requirements which are communicated to the kitchen. Some dry goods were viewed past their use by date in the store.
Safe and Appropriate Environment
Policies and procedures are implemented to ensure staff and consumers are protected from harm due to waste, infectious or hazardous substances.
A maintenance programme is in place for the building and equipment, and a current building warrant of fitness is in place. Appropriate equipment is provided to maximise independence and non-slip surfaces are provided in wet areas. Ramps, handrails and good transitions are provided. The dementia area is secure both externally and internally with keypad access. A combination of ensuites and shared facilities are provided.
Adequate hand washing facilities are provided and infection control information is displayed. Fixtures, fittings and surfaces are able to be cleaned in line with infection control requirements and facilities are identified. Adequate space is provided to allow safe movement around personal space and beds in consumers' rooms. No bed transfers are undertaken in the hospital or rest home, with processes in place to enable hospital residents to transfer without beds.
Multiple lounges and dining areas are provided, each service has its own designated areas. The bulk of the laundry is processed at another Anglican Aged Care facility which was visited as part of the audit. Minimal personal and cleaning laundry is done at the
Fitzgerald Complex. Appropriate policies and procedures are in place and three-monthly audits are completed. Consumers on interview confirm effective laundry and cleaning processes. Emergency training is completed and regular evacuation drills are conducted. Emergency equipment is current. There is an approved evacuation plan in place and emergency civil defence planning is in place. A call bell system is in place and a documented security policy is in place with education provided.
Restraint Minimisation and Safe Practice
Fitzgerald has fostered an environment of minimal restraint use and utilisation of alternative strategies. Implemented policies ensure that when restraint is used appropriate approval is obtained, comprehensive assessment is undertaken, regular monitoring occurs and ongoing evaluations are conducted. A multi disciplinary approach is taken incorporating input from residents if possible and family members.
There are clear and detailed records of all restraint use. Staff have regular training in all aspects of the policy and procedures.
Infection Prevention and Control
The infection control programme has been developed by the Selwyn Foundation Group with expert input. At Fitzgerald a registered nurse is the designated infection control nurse but all aspects of the programme are overseen by the clinical coordinator. Rates of infection are similar to other facilities within the Selwyn Foundation Group.
Policies and procedures are regularly reviewed to ensure they align with current good practice and legislative requirements.
Care giving staff receive regular in-service sessions on hand washing techniques. Surveillance is undertaken relevant to the size and scope of the facility. This data is utilised to identify opportunities for improvement and educational requirements.
Standards have been assessed and summarised below:
Key
Five point scale Description
Standards applicable to this service attained with some criteria exceeded
Includes commendable elements above the required levels of performance Standards applicable to this service
attained with all criteria achieved
Complies with standards Standards applicable to this service
attained with some criteria of low risk partially achieved
Some minor shortfalls, no major deficiencies and required levels of performance seem achievable without extensive extra activity
Standards applicable to this service attained with some criteria of moderate or high risk partially achieved or
unachieved
A moderate number of shortfalls that require specific action planning to address
Some standards or this standard unattained that are applicable to this service
Major shortfalls, significant action is needed to achieve the required levels of performance
Consumer Rights Assessment
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 attained with some criteria of moderate or high risk partially
achieved or any criteria
unachieved
Organisational Management Assessment
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 attained with some criteria of moderate or high risk partially
achieved or any criteria
unachieved
Continuum of Service Delivery Assessment
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.
Standards applicable to this service attained with some criteria of moderate or high risk partially
achieved or any criteria
unachieved
Safe and Appropriate Environment Assessment
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 attained with some criteria of moderate or high risk partially
achieved or any criteria
unachieved
Restraint Minimisation and Safe Practice Assessment
Includes 3 standards with outcomes where:
- Consumers receive and experience services in the least restrictive manner through restraint minimisation
- Consumers requiring restraint receive services in a safe manner
- Consumers requiring seclusion receive services in the least restrictive manner
Standards applicable to this service attained with all criteria
achieved
Infection Prevention and Control Assessment
Includes 6 standards which require:
- There is a managed environment, which minimises the risk of infection to consumers, service providers and visitors
appropriate to the size and scope of the service. - There are adequate human, physical and information
resources to implement the infection control programme and meet the needs of the organisation.
- Documented policies and procedures for the prevention and control of infection reflect current accepted good practice and relevant legislation requirements and are readily available and are implemented in the organisation. These policies and procedures are practical, safe and appropriate/suitable for the type of service provided.
- The organisation provides relevant education on infection control to all service providers, support staff and consumers. - Surveillance for infection is carried out in accordance with
agreed objectives, priorities and methods that have been specified in the infection control programme.
- Acute care and surgical hospitals will have established and implemented policies and procedures for the use of antibiotics to promote the appropriate prudent prescribing in line with accepted guidelines. The service can seek guidance from clinical microbiologists or infectious disease physicians.
Standards applicable to this service attained with some criteria of low risk
partially achieved
