Executive Summary of Audit General Overview Metlifecare Palmerston North is owned and operated by Metlifecare Limited. On the day of audit 34 beds are occupied consisting of 26 hospital level care residents and eight rest home level residents. Seven of the nine areas identified as requiring improvement in the previous audit have been addressed two areas remain open. There are three new areas identified for improvement related to corrective action outcome management, staff orientation and assessment processes. Outcome 1.1: Consumer Rights The residents and family/whanau interviewed report that there is a good standard of communication at the service and that information is conveyed in an open and honest manner. Access to interpreter services is documented in the interpreter service policy, which contains contact numbers for interpreter services. All complaints sighted are recorded appropriately to meet policy requirements. This was an area identified for improvement in the previous audit and is now fully attained. Outcome 1.2: Organisational Management Organisational structures and processes are monitored by Metlifecare head office via an electronic system (Amrisk). The purpose, values, scope, direction and goals of the organisation are clearly documented and regularly reviewed. Documentation identifies key components of service delivery are reported on a quarterly basis at organisational level, and monthly basis at staff meetings. Service delivery is overseen by the nurse manager (a registered nurse) who has been in the role for seven years. She is supported by the village manager. A signed job description identifies that the nurse manager has the authority, accountability and responsibility for ensuring the provision of services meets residents’ needs. Corrective action planning is documented, but does not have any identified outcomes, as is required by policy to show effectiveness of actions taken. This requires improvement. Incidents, accidents and adverse events are recorded, reported, evaluated and benchmarked at organisational level and information is shared with all facility staff. Family/whanau are kept informed and communication related to an event reflects the principles of open disclosure. Not all information shown on incident and accident forms is followed up to ensure corrective actions are being used as opportunities for improvement. This was an area identified for improvement in the previous audit and is yet to be addressed. There is an up-to-date risk register which outlines controls that are in place to minimise known and potential risks. The service has an up to date disaster management plan in place which identifies contingency measures to be taken by the site manager at Metlifecare Palmerston North. The service is able to
service delivery, and to identify and manage risk. is no documented evidence that this information is being actively used to improve service delivery. One example relates to a resident who displays challenging behaviour. The incident form identifies that a challenging behaviour log is to be put in place. No log could be found in the resident’s file. HDS(C)S.2008 Standard 1.2.7: Resource Management resource management processes are conducted in accordance with good employment practice and meet the requirements of legislation. PA Low HDS(C)S.2008 Criterion 1.2.7.4 New service providers receive an orientation/induction programme that covers the essential components of the service provided. PA Low On the day of audit not all staff files could be accessed as the village manager is away on annual leave for three weeks and no one else at the facility can access the files for the staff she manages. This includes domestic staff from the laundry, cleaning and kitchen areas. 2. A review of a recently employed RN’s file identifies that none of the orientation criteria has been signed off. Ensure all orientation processes are undertaken and signed off when completed and that staff files are accessible to management at all times. 180 HDS(C)S.2008 Standard 1.2.9: Consumer Information Consumer information is uniquely identifiable, accurately recorded, current, confidential, and accessible when required. PA Low
Management Systems HDS(C)S.2008 Criterion 1.2.9.9 All records are legible and the name and designation of the service provider is identifiable. PA Low Not all progress note entries in the five of five residents’ files have entries that record the staff member’s name, signature and designation. Ensure all progress note entries have the name and designation of the service provider identifiable. 180 HDS(C)S.2008 Standard 1.3.4: Assessment Consumers' support requirements, and preferences are gathered and recorded in a timely manner. PA Low HDS(C)S.2008 Criterion 1.3.4.2 The needs, outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning. PA Low Assessment identifies varying needs levels with no documented corresponding referrals sighted. Ensure the needs of the residents identified through the assessment process are responded to within appropriate timeframes to ensure the correct level of service delivery is offered. 180 Continuous Improvement (CI) Report Code Name Description Attainment Finding NZS 8134.1:2008: Health and Disability Services (Core) Standards
Criterion 2.1.1.4 (HDS(RMSP)S.2008:2.1.1.4) The use of enablers shall be voluntary and the least restrictive option to meet the needs of the consumer with the intention of promoting or maintaining consumer independence and safety. Attainment and Risk: FA Evidence: Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.) NZS 8134.3:2008: Health and Disability Services (Infection Prevention and Control) Standards Standard 3.3: Policies and procedures (HDS(IPC)S.2008:3.3) Documented policies and procedures for the prevention and control of infection reflect current accepted good practice and relevant legislative 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. ARC D5.4e, D19.2a ARHSS D5.4e, D19.2a Attainment and Risk: FA Evidence: At the request of the DHB the audit team is requested to further look into the policies and procedures around infection control, norovirus management and after hours communication with the hospital, family and DHB. The policies sighted are clearly written and comply with relevant legislation and current accepted good practice. To ensure the provision of a service which is consistently safe the Infection Control Work Instructions have been developed to provide a reference and guide to ensure that best practice is followed at all times in the prevention and control of infections within Metlifecare, including residents and all other personnel. Associated documents include the use of a specialist infection control advisory services’ manual, resources and education as the expert advice for infection prevention and control matters. This manual covers the policies and procedures for the management of outbreaks, including gastroenteritis related illness. The service also has Public Health and Ministry of Health guidelines for outbreak management guidelines for gastroenteritis and guidelines specifically for management of Norovirus. The service implements actions based on the infection control manual and public health guidelines. The infection control officer has taken on the role of the outbreak manager. Families of residents in the care facility were first contacted through