Bupa Care Services NZ Limited - Parkwood Rest Home & Hospital

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: Bupa Care Services NZ Limited

Premises audited: Parkwood Rest Home & Hospital

Services audited: Hospital services - Medical services; Hospital services - Geriatric services (excl. psychogeriatric); Rest home care (excluding dementia care); Residential disability services - Intellectual; Residential disability services - Physical; Residential disability services – Sensory

Dates of audit: Start date: 11 February 2015 End date: 12 February 2015

Proposed changes to current services (if any): None

Total beds occupied across all premises included in the audit on the first day of the audit: 105

Bupa Care Services NZ Limited - Parkwood Rest Home & Hospital Date of Audit: Page 1 of 23

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 All standards applicable to this service fully attained with required levels of some standards exceeded performance

Bupa Care Services NZ Limited - Parkwood Rest Home & Hospital Date of Audit: Page 3 of 23 Indicator Description Definition

No short falls Standards applicable to this service fully attained

Some minor shortfalls but no major deficiencies and required levels of Some standards applicable to this service partially performance seem attained and of low risk achievable without extensive extra activity A number of shortfalls Some standards applicable to this service partially that require specific attained and of medium or high risk and/or unattained action to address and of low risk Major shortfalls, significant action is Some standards applicable to this service unattained and needed to achieve the of moderate or high risk required levels of performance

General overview of the audit

Parkwood Rest Home and Hospital provides rest home, hospital and individual contract care for up to 129 residents. On the day of audit there were 105 residents. The service is managed by a facility manager. The residents and relatives interviewed all spoke positively about the care and support provided.

This unannounced surveillance audit was conducted against a sub-set of the relevant 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, management and staff. The service has addressed the two findings from the previous audit in relation to short term care plans and transcribing on medication signing sheets. The service is commended for maintaining continued improvement ratings around implementation of quality goals, quality improvements, analysis and corrective actions around adverse events and the education programme. This audit identified two improvements required around aspects of care planning and medication administration.

Consumer rights Includes 13 standards that support an outcome where consumers receive safe services of an Standards applicable appropriate standard that comply with consumer rights legislation. Services are provided in a to this service fully manner that is respectful of consumer rights, facilities, informed choice, minimises harm and attained. acknowledges cultural and individual values and beliefs.

Parkwood Rest Home and Hospital provides care in a way that focuses on the individual residents' quality of life. There is a Maori Health Plan and implemented policy supporting practice. Cultural assessment is undertaken on admission and during the review process. Information about the Health and Disability Commissioner (HDC) Code of Health and Disability Services Consumers' Rights (the Code) is readily available to residents and families. Policies are being implemented to support residents’ rights. Resident rights’ has been included in the annual staff training programme. Care plans accommodate the choices of residents and/or their family. Informed consent is sought and advanced directives were appropriately recorded. Complaint processes were being implemented and complaints and concerns have been managed and documented. Residents and family interviewed verified on-going involvement with the community.

Organisational management All standards applicable to this Includes 9 standards that support an outcome where consumers receive services that comply service fully attained with legislation and are managed in a safe, efficient and effective manner. with some standards exceeded

Bupa Care Services NZ Limited - Parkwood Rest Home & Hospital Date of Audit: Page 5 of 23 Parkwood has an established quality and risk management system that supports the provision of clinical care and support. Key components of the quality management system link to a number of meetings including quality meetings. An annual resident/relative satisfaction survey is completed and there are regular resident/relative meetings. Quality and risk performance is reported across the facility meetings and also to the organisation's management team. Four benchmarking groups across the organisation are established for rest home, hospital, dementia, and psychogeriatric/mental health services. Parkwood is benchmarked in two of these (rest home and hospital). The robust systems for quality and risk management are continually being reviewed at both an organisational level and at Parkwood. Benchmarking and audit data demonstrate that they have achieved good standards of care and service.

Quality actions have resulted in a number of quality improvements for both residents and staff. There is an active health and safety committee. There are human resources policies including recruitment, selection, orientation and staff training and development. The service has in place a comprehensive orientation programme that provides new staff with relevant information for safe work practice. There is a comprehensive in-service training programme covering relevant aspects of care and support and external training is well supported. The organisational staffing policy aligns with contractual requirements and includes skill mixes. Staffing levels are monitored closely with staff and resident input into rostering. Continuous improvement ratings have been awarded around the continued implementation of the quality system and education programme.

Continuum of service delivery Some standards applicable to this Includes 13 standards that support an outcome where consumers participate in and receive service partially timely assessment, followed by services that are planned, coordinated, and delivered in a attained and of timely and appropriate manner, consistent with current legislation. medium or high risk and/or unattained and of low risk

The registered nurses are responsible for each stage of service provision. The assessments and care plans are developed in consultation with the resident/family/whanau. The service has addressed a previous audit finding around aspects of care planning. The activity programme is varied and appropriate to the level of abilities of the residents. Medications are managed, stored, and administered with supporting documentation. The service has addressed a previous finding relating to administration practice. Medication training and competencies are completed by all staff responsible for administering medicines. Food is prepared on site with individual food preferences, dislikes and dietary requirements assessed by the registered nurses and a dietitian.

Safe and appropriate environment Includes 8 standards that support an outcome where services are provided in a clean, safe Standards applicable environment that is appropriate to the age/needs of the consumer, ensure physical privacy is to this service fully maintained, has adequate space and amenities to facilitate independence, is in a setting attained. appropriate to the consumer group and meets the needs of people with disabilities.

The building has a current warrant of fitness.

Restraint minimisation and safe practice Standards applicable Includes 3 standards that support outcomes where consumers receive and experience to this service fully services in the least restrictive and safe manner through restraint minimisation. attained.

Documentation of policies and procedures and staff training demonstrate residents are experiencing services that are the least restrictive. There are eight hospital and five young persons with disability residents requiring an enabler and ten hospital and two young persons with disability requiring a restraint.

Bupa Care Services NZ Limited - Parkwood Rest Home & Hospital Date of Audit: Page 7 of 23 Infection prevention and control Includes 6 standards that support an outcome which minimises the risk of infection to All standards consumers, service providers and visitors. Infection control policies and procedures are applicable to this practical, safe and appropriate for the type of service provided and reflect current accepted service fully attained good practice and legislative requirements. The organisation provides relevant education on with some standards infection control to all service providers and consumers. Surveillance for infection is carried exceeded out as specified in the infection control programme.

The infection control programme was appropriate for the size and complexity of the service. The infection control officer used the information obtained through surveillance to determine infection control activities, resources and education needs within the facility. This included audits of the facility, hand hygiene and surveillance of infection control events and infections. The service engaged in benchmarking with other Bupa facilities.

Summary of attainment

The following table summarises the number of standards and criteria audited and the ratings they were awarded.

Partially Partially Partially Partially Continuous Partially Attained Fully Attained Attained Attained Attained High Attained Critical Attainment Improvement Low Risk Rating (FA) Negligible Risk Moderate Risk Risk Risk (CI) (PA Low) (PA Negligible) (PA Moderate) (PA High) (PA Critical) Standards 5 9 0 1 1 0 0 Criteria 6 33 0 1 1 0 0

Unattained Unattained Low Unattained Unattained High Unattained Attainment Negligible Risk Risk Moderate Risk Risk Critical Risk Rating (UA Negligible) (UA Low) (UA Moderate) (UA High) (UA Critical) Standards 0 0 0 0 0 Criteria 0 0 0 0 0 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 Attainment Audit Evidence Rating

Standard 1.1.9: Communication FA Residents and family members interviewed stated they are informed of changes in health status and incidents/accidents. Residents and family members also stated they Service providers communicate effectively with were welcomed on entry and were given time and explanation about services and consumers and provide an environment conducive to procedures. Resident/relative meetings take place and the manager and registered effective communication. nurses have an open-door policy. Residents and family are advised in writing of their eligibility and the process to become a subsidised resident should they wish to do so. The service has policies and procedures available for access to interpreter services and residents (and their family/whānau). If residents or family/whanau have difficulty with written or spoken English then the interpreter services are made available

Standard 1.1.13: Complaints Management FA The organisational complaints policy is implemented at Parkwood. The facility manager has overall responsible for ensuring all complaints (verbal or written) are fully The right of the consumer to make a complaint is documented and investigated. A feedback form is completed for each complaint understood, respected, and upheld. recorded on the complaint register. There is a complaints register maintained that includes relevant information regarding the complaint. Documentation including follow up letters and resolution are available. Verbal complaints were included and actions and response documented. The number of complaints received each month are reported monthly to staff via the various meetings. Discussion with residents (three

Bupa Care Services NZ Limited - Parkwood Rest Home & Hospital Date of Audit: Page 9 of 23 rest home, three hospital and three young persons with disability) and relatives (three rest home and three hospital) confirmed they are provided with information on the complaints process. Feedback forms are available for residents/relatives in various places around the facility. A complaints procedure was provided to residents within the information pack at entry.

Standard 1.2.1: Governance CI Parkwood is a Bupa facility. The service provides rest home, hospital and residential disability level care for up to 129 residents. There were 105 residents in the facility on The governing body of the organisation ensures the day of audit including, 55 rest home (of which there were three YPD and three services are planned, coordinated, and appropriate to respite) and 50 hospital level residents (of which there were ten YPD). There is a the needs of consumers. contracted physiotherapist that provided 25 hours a week, and a contracted medical centre providing general practitioner services. Bupa has an organisational total quality management plan and a policy outlining the purpose, values and goals. Quality objectives and quality initiatives from an organisational perspective are set annually and each facility then develops their own specific objectives. Parkwood was in the process of confirming 2015 objectives at the time of audit and these will include a continuation of the falls reduction program with the aim of reducing falls by 50%. The facility manager (registered nurse) at Parkwood has been in the role for approximately five years (also managers another Christchurch facility), and has worked with Bupa for an approximately eight years. She is supported by a clinical manager (registered nurse) who oversees clinical care. The clinical manager had been in post for five years and provides peer support and supervision to clinical managers in other Bupa facilities. The management team is supported by the wider Bupa management team including a regional operations manager. The facility manager and clinical manager have maintained professional development related to managing a facility. The managers are supported by a unit coordinator in both the rest home and hospital units. Bupa provides a comprehensive orientation and training/support programme for their managers. Managers and clinical managers attend annual organisational forums and regional forums six monthly. Bupa has robust quality and risk management systems implemented across its facilities. Across Bupa, four benchmarking groups are established for rest home, hospital, dementia, psychogeriatric/mental health services. Benchmarking of some key clinical and staff incident data is also carried out with facilities in the UK, Spain and Australia. e.g. Mortality and Pressure incidence rates and staff accident and injury rates. The facility has maintained a continuous Improvement rating around implementing organisational and facility level goals.

Standard 1.2.3: Quality And Risk Management CI Parkwood has a well-established quality and risk management system. Interviews Systems with staff and review of meeting minutes/quality action forms/toolbox talks demonstrate a continued culture of quality improvements. Quality and risk performance is reported The organisation has an established, documented, and across the facility meetings, through the communication book, and also to the maintained quality and risk management system that organisation's management team. reflects continuous quality improvement principles. The service has policies and procedures and associated implementation systems to provide a good level of assurance that it is meeting accepted good practice and adhering to relevant standards - including those standards relating to the Health and Disability Services (Safety) Act 2001. Key components of the quality management system link to the two monthly quality committee through quality reports provided from departments. Weekly reports by facility manager to Bupa operations manager and quality indicator reports to Bupa quality coordinator provide a coordinated process between service level and organisation. Parkwood is commended for continued implementation of the quality and risk management process. The facility manager provides a documented weekly report to Bupa regional manager. A monthly summary of each facility within the Operations Managers region is also provided for the Operations Manager which shows cumulative data regarding each facilities progress with key indicators – clinical indicators / H&S staff indicators etc. throughout the year. Benchmarking reports are generated throughout the year to review performance over a 12 month period. Quality action forms are utilised at Parkwood and document actions that have improved outcomes or efficiencies in the facility. The service continues to collect data to support the implementation of corrective action plans. Responsibilities for corrective actions are identified. Reports provided to the quality meeting (such as health and safety and infection control) include areas identified for improvement and actions initiated. There is a comprehensive H&S and risk management programme in place. Bupa also has a H&S coordinator whom monitors staff accidents and incidents. There is a Bupa Health & Safety Plan; on-going review is seen in H&S meeting minutes. Falls 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. This has

Bupa Care Services NZ Limited - Parkwood Rest Home & Hospital Date of Audit: Page 11 of 23 included particular residents identified as high falls-risk and the use of hip protectors, hi/lo beds, assessment and exercises by the physiotherapy team, landing strips by beds and sensor mats.

Standard 1.2.4: Adverse Event Reporting CI The service documents and analyses incidents/accidents, unplanned or untoward events and provides feedback to the service and staff so that improvements are made. All adverse, unplanned, or untoward events are Individual incident reports are completed for each incident/accident with immediate systematically recorded by the service and reported to action noted and any follow up action required. The data is linked to the organisation's affected consumers and where appropriate their benchmarking programme and this is used for comparative purposes. Minutes of the family/whānau of choice in an open manner. quality meetings, staff meetings and peer review meeting reflect a discussion of benchmarking results. Ten incident/accident forms were reviewed for January 2015. All demonstrated clinical follow up by a registered nurse, communication with the family, Staff interviewed demonstrated a good understanding of the process for reporting adverse events. GP and physiotherapy assessment if an injury occurred or a minimisation plan was required if the risk of a repeat incident was indicated. Neurological observations were recorded for all residents with unwitnessed or head injury falls. Quality Indicators - Analysis and corrective action plan policy (284) includes and objective ' corrective actions will be identified and implemented in response to increases or adverse trends in monthly resident incidents and infection rates. The management are aware of their statutory obligations in relation to essential notification reporting to the correct authority.

Standard 1.2.7: Human Resource Management CI There are organisational policies to guide recruitment practices and documented job descriptions for all positions. There are also job descriptions for all roles. Appropriate Human resource management processes are recruitment documentation was seen in the seven staff files reviewed. A register of conducted in accordance with good employment practising certificates is maintained. Performance appraisals are current in all files practice and meet the requirements of legislation. reviewed. Interview with the management team (facility manager and clinical manager) inform a stable workforce. Interview with caregivers and registered nurses informed that management are supportive and responsive. There is an annual training plan that was being implemented. Bupa ensures registered nurses (RN) are supported to maintain their professional competency. There is an education session held weekly as well as toolbox talks. There is an induction programme with completion being monitored and reported monthly to head office as part of the reporting programme. Interviews with staff informed the induction programme meets the requirements of the service.

Standard 1.2.8: Service Provider Availability FA The facility manager and clinical manager are both registered nurses (RNs) and provide additional RN cover Monday – Friday (8am – 5pm). They are supported by a Consumers receive timely, appropriate, and safe RN unit manager in both the rest home and hospital. A four week rotating roster is in service from suitably qualified/skilled and/or place with three RN’s in the hospital on morning and afternoon shifts and two on duty experienced service providers. at night. The rest home have at least one RN on duty for all shifts. Staff, residents and relatives interviewed stated that sufficient staff are rostered for each shift.

Standard 1.3.12: Medicine Management PA Moderate There are policies and procedures in place for safe medicine management that meet legislative requirements. All clinical staff who administer medications have been Consumers receive medicines in a safe and timely assessed for competency on an annual basis. Education around safe medication manner that complies with current legislative administration has been provided. One of three registered nurses was observed requirements and safe practice guidelines. safely administering medications. Registered nurses and care staff interviewed were able to describe their role in regard to medicine administration. The service has addressed and monitored a previous finding relating to medication administration practice. A contracted pharmacy supplies packed medications. Three of 14 medication charts reviewed had documented indication for use of as required medication by the GP. Twelve of fourteen medication charts had appropriate charting of the medication by the GP. Two of fourteen medication charts sampled met all the prescribing requirements. Each drug chart has a photo identification of the resident and allergies or nil known allergies are recorded on the medication chart. Residents who wish to self-medicate are appropriately assessed and supported to do so. Internal medication audits are conducted six monthly. The medication charts reviewed identified that the GP had seen and reviewed the resident three monthly. The facility manager and clinical manager have met with the house GPs in January 2015 and discussed requirements around medication charts.

Standard 1.3.13: Nutrition, Safe Food, And Fluid FA All meals at Bupa Parkwood are prepared and cooked on site. There is a six weekly Management winter and summer menu which had been reviewed by a dietitian. Meals are prepared in a well-appointed kitchen adjacent to the rest home dining room. Residents are A consumer's individual food, fluids and nutritional provided with meals on trays; however, this has been reviewed and a plan is in place needs are met where this service is a component of to implement bain marie service in 2015. Kitchen staff are trained in safe food service delivery. handling and food safety procedures were adhered to. Staff were observed assisting residents with their lunch time meals and drinks. Diets are modified as required. Resident dietary profiles and likes and dislikes are known to food services staff and any changes are communicated to the kitchen via the registered nurse or nurse manager. Supplements are provided to residents with identified weight loss issues.

Bupa Care Services NZ Limited - Parkwood Rest Home & Hospital Date of Audit: Page 13 of 23 Weights are monitored monthly or more frequently if required and as directed by a dietitian. Resident meetings and surveys allow for the opportunity for resident feedback on the meals and food services generally. Residents and family members interviewed indicated satisfaction with the food service

Standard 1.3.6: Service Delivery/Interventions PA Low A written record of each resident’s progress is documented. Changes are followed up by a registered nurse (evidenced in all residents' progress notes sighted). When a Consumers receive adequate and appropriate services resident's condition alters, the registered nurse initiates a review and if required, a GP in order to meet their assessed needs and desired consultation or referral to the appropriate health professional is actioned. When a outcomes. resident health needs change or at the six monthly care plan review the registered nurse updates the residents care plan to reflect current health care needs as evidenced in four of seven resident files reviewed. The clinical staff interviewed advised that they have all the equipment referred to in care plans necessary to provide care. Dressing supplies are available and a treatment rooms are well stocked for use. Wound documentation was reviewed and includes wound assessment, treatment plans and evaluations and progress notes. The wound care nurse specialist was involved with assessment and treatment of chronic wounds and is available for advice. Continence products are available and specialist continence advice is available as needed. Short term care plans are recorded and plans reviewed documented sufficient detail to guide care staff in the provision of care. A physiotherapist and physiotherapist assistant are employed to assess and assist resident’s mobility and transfer needs.

Standard 1.3.7: Planned Activities FA The activities staff at Bupa Parkwood provide an activities programme over five days per week and volunteers assist at the weekend. Group activities are voluntary and Where specified as part of the service delivery plan for developed by the activities staff. Residents are able to participate in a range of a consumer, activity requirements are appropriate to activities that are appropriate to their cognitive and physical capabilities. The service their needs, age, culture, and the setting of the service. has two vans which are used for resident outings. The group activity plans are displayed on notice boards around the facility. There are two programmes and residents can choose which activity they wish to attend. All residents who do not participate regularly in the group activities are visited by a member of the activity staff with records kept to ensure all such residents are included. All interactions observed on the day of the audit indicated a friendly relationship between residents and activity staff. The resident files reviewed included a section of the care plan was for activity and is reviewed six monthly. Residents interviewed spoke very positively of the activity programme with feedback and suggestions for activities made via meetings and surveys. The organisation has an occupational therapist that oversees the activity programme, is available for activity staff to discuss recreational programmes and provides education for activity staff twice a year.

Standard 1.3.8: Evaluation FA Initial care plans are evaluated within three weeks of admission. Long term care plans are reviewed and evaluated by the registered nurses or when changes to care occur (# Consumers' service delivery plans are evaluated in a link 1.3.6.1). A multi-disciplinary team meeting is conducted six monthly for each comprehensive and timely manner. resident and involves all relevant personnel. The house GP examines the residents and review the medications three monthly with a full medical review six monthly. Short term care plans focus on acute and short term needs and files reviewed had short term care plans evaluated and resolved or on-going long term problems recorded in the long term care plan. This was a previous audit finding that has now been addressed.

Standard 1.4.2: Facility Specifications FA The service holds a current Building Warrant of Fitness which expires on 1 February 2016. Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for their purpose.

Standard 3.5: Surveillance CI The surveillance policy describes and outlines the purpose and methodology for the surveillance of infections. The infection control coordinator uses the information Surveillance for infection is carried out in accordance obtained through surveillance to determine infection control activities, resources, and with agreed objectives, priorities, and methods that education needs within the facility. have been specified in the infection control programme. Individual infection records are completed for all infections. This is kept as part of the resident files. Infections are included on a monthly register and a monthly report is completed by the infection control co-ordinator. Definitions of infections are in place appropriate to the complexity of service provided. Infection control data is collated monthly and reported at the quality, and infection control meetings. The meetings include the monthly infection control report. The surveillance of infection data assists in evaluating compliance with infection control practices. The infection control programme is linked with the quality management programme. The results are subsequently included in the Manager’s report on quality indicators. Internal infection control audits also assist the service in evaluating infection control needs. There is close liaison with the GP's that advise and provide feedback /information to the service. Systems in place are appropriate to the size and complexity of the facility. Quality Improvement initiatives are taken and recorded as part of continuous improvement. Documentation covers a summary, investigation, evaluation and action taken. The service is commended for their continued improvement approach around follow up actions of infections and clinical indicators.

Bupa Care Services NZ Limited - Parkwood Rest Home & Hospital Date of Audit: Page 15 of 23 During December 2014 a number of residents (ten in total) experienced norovirus. This was reported to Public Health. A summary was completed that included documented positives, and area for improvements.

Standard 2.1.1: Restraint minimisation FA Restraint policy is in place. There is a documented definition of restraint and enablers, which is congruent with the definition in NZS 8134.0. The policy includes Services demonstrate that the use of restraint is comprehensive restraint procedures. The process of assessment and evaluation of actively minimised. enabler use is the same as a restraint and included in the policy. The service has 12 (10 hospital and two young persons with disability) residents requiring restraint with bedrails and wheel chair seat belts. The service has 13 residents (eight hospital and five young persons with disability) using bedrails and one wheel chair seat belt as enablers. Enablers are assessed as required for maintaining safety and independence. Enablers are used voluntarily. One of the Bupa quality goals is to safely reduce the use of restraint of which the service is fully committed to. The number of residents requiring restraint at the service has reduced. The rest home has remained restraint free for over five years. Training has been provided around restraint, enablers and challenging behaviours. The restraint standards are being implemented and implementation is reviewed through internal audits, facility meetings, regional restraint meetings and at an organisational level. 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 Attainment Audit Evidence Audit Finding Corrective action required outcome Rating and timeframe for completion (days)

Criterion 1.3.6.1 PA Low Residents long term care plans and risk (i) One rest home resident (i), (ii), (iii) Ensure that all assessments (includes InterRAI assessment) are had a dietitian review with interventions in the long term The provision of services reviewed six monthly or sooner if required. recommendations around care plan are updated to and/or interventions are There is a six month medical review by the GP food choices. These reflect resident current health consistent with, and and a six monthly multi-disciplinary meeting. interventions were not care needs and that all contribute to, meeting the Following review of the resident health care updated in the long term care documentation is consistent consumers' assessed needs the registered nurse updates the long plan. (ii) One hospital to guide staff and enable safe needs, and desired term care plan so as to guide staff to safely resident following a MDT care delivery and support. outcomes. deliver and support the resident health care meeting did not have 90 Days needs. This was evident in three of seven interventions updated to resident files reviewed. reflect family request for rest time after lunch, sheepskin on the lazy boy chair, use of a toileting aid and continence requirements. (iii) One hospital resident with mobility and transfer issues did not have interventions updated in the long term care plan that

Bupa Care Services NZ Limited - Parkwood Rest Home & Hospital Date of Audit: Page 17 of 23 reflected the latest MDT meeting, the transfer plan and care summary. There was no consistency with reviews of mobility.

Criterion 1.3.12.1 PA Registered nurses, enrolled nurses and (i) Two registered nurses (i) Ensure that medications Moderate caregivers who are duty leaders in the rest home were observed checking the are signed for after observing A medicines management administer medications. All staff administering packaged medication against the resident has taken the system is implemented to medications have completed medication the residents prescribed medication prescribed. (ii) manage the safe and competency assessments annually. Three medication chart safely Ensure that all ‘as required’ appropriate prescribing, registered nurses were observed administering however the registered medications have a dispensing, administration, medications at lunch time to residents (one in the nurses signed for the documented indication for review, storage, disposal, rest home and two in the hospital). One medication before use by the GP so as to safely and medicine reconciliation registered nurse safely administered approaching the resident and guide staff in medication in order to comply with medications. Indication for use of as required observing the resident taking administration. (iii) Ensure legislation, protocols, and medications was documented by the GP on the prescribed medication. that the GP signs each guidelines. three of the medication chats reviewed. This (ii) In eleven medication individual prescribed included but not limited to; charted medications charts reviewed the GP had medication on the residents for pain control, management of nausea and not documented the medication chart. management of shortness of breath. Twelve indication for use of as 30 Days medication charts reviewed had each prescribed required medications so as to medication signed by the GP. safely guide staff in medication administration. Medications charted for as required medications included but not limited to; pain management and anxiety management. (iii) On two medication charts reviewed the GP had signed a number of medications with an arrow indication and there for each medication was not individually signed. 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.

Criterion with Attainment Audit Evidence Audit Finding desired outcome Rating

Criterion 1.2.1.1 CI Parkwood is part of the Bupa group of facilities and provides Parkwood continues to demonstrate a continued care for up to 129 residents across two floors. There were 105 improvement process around implementation of quality The purpose, residents at the time of audit. Bupa's overall vision is "Taking goals. Quarterly quality reports on progress towards values, scope, care of the lives in our hands". There are six key values that meeting the quality goals identified. Meeting minutes direction, and goals are displayed on the wall. In 2009, Bupa introduced a person reviewed included discussion on going progress to of the organisation centred care focus which includes six pillars. This has been meeting their goals. Parkwood annual goals also link to are clearly embedded in service delivery at Parkwood. the organisations goals and this is also reviewed in identified and quality meetings and also in each of the staff/other regularly reviewed. There is an overall Bupa business plan and risk management meetings. This provides evidence that the quality goals plan. Additionally, each Bupa facility develops an annual quality are a 'living document'. The service achieved their two plan. Parkwood set specific quality goals for 2015 including 2014 goals. One goal ‘to have 25% of residents with a (but not limited to) a) moving to a new site and facility, b) 50% completed InterRAI assessment this year’. Was achieved reduction in falls, c) reduction in restraint use, d) providing care by September 2014. for residents on new and individual contracts to meet the needs of the community. The Bupa Quality and Risk team provides a bi-monthly clinical

Bupa Care Services NZ Limited - Parkwood Rest Home & Hospital Date of Audit: Page 19 of 23 newsletter called Bupa Nurse which provides a forum to explore clinical issues, ask questions, share experiences and updates with all qualified nurses in the company. The Bupa geriatrician provides newsletters to GPs.

Criterion 1.2.3.6 CI The service continues to implement a comprehensive quality Parkwood continues to implement corrective actions as a and risk management process. Monitoring in each area is result of quality indicators being above the benchmark. Quality completed monthly, quarterly, six monthly or annually as Feedback is provided to Parkwood via graphs and improvement data designated by the internal auditing programme schedule. benchmarking results are discussed. Corrective action are collected, plans were completed where benchmarking was above analysed, and Audit summaries and action plans are completed as required i.e.: falls above KPI in July and September in rest home. evaluated and the depending on the result of the audit. Key issues are reported A QI- corrective action plan was established. Toolbox results to the appropriate committee e.g. quality, staff, and an action talks provided. The facility manager provides a communicated to plan is identified. These were comprehensively addressed in documented weekly report to Bupa operations manager. service providers meeting minutes sited. A quality action form was implemented around reducing and, where There is also a number of on-going quality improvements antipsychotic medication for residents. The evaluation appropriate, identified through meeting minutes and as a result of analysis of identified this was achieved with reduction across all consumers. quality data collected. Parkwood is proactive in developing and areas and Parkwood was below the 20% Bupa Goal for implementing quality initiatives. All meetings include excellent 2014. feedback on quality data where opportunities for improvement are identified.

Criterion 1.2.3.7 CI The service plans and operational structures combine to Quality action forms continue to be utilised at Parkwood provide a comprehensive quality development and risk and document actions that have improved or enhanced a A process to management structure. Monthly benchmarking occurs current process or system or those actions which have measure throughout the group. Clinical and non-clinical indicators are improved outcomes or efficiencies in the facility. Audit achievement monitored and facility performance is measured against these. results are collated and documented on the audit against the quality Benchmarking reports are generated throughout the year to summary sheet, where corrective actions are identified and risk review performance over a 12 month period. and implemented. Results are then fed back to staff at management plan appropriate forums, e.g. quality meeting, resident and is implemented. Parkwood continues to hold comprehensive two monthly quality staff meeting. Benchmarking reports continue to be and risk management meetings. These meetings include generated throughout the year to review performance reviewing progress to meeting their annual quality goals. over a 12 month period. Improvements have been made Progress is forwarded to the quality management coordinator including (but not limited to); (i) quality action around for Bupa. achieving 100% flu vax for residents. This was achieved through education and working as a team to get residents and relatives on side; (ii) review of physio assistant schedule to reflect change in resident needs. Looking for more interactive ways to engage residents in exercise/activity one-on-one and group. Feedback from residents is that this is working well.

Criterion 1.2.4.3 CI The service documents and analyses incidents/accidents, The service continues to documents and analyses unplanned or untoward events and provides feedback to the incidents/accidents, unplanned or untoward events and The service service and staff so that improvements are made. Individual provides feedback to the service and staff so that provider documents incident reports are completed for each incident/accident with improvements are made. Individual incident reports are adverse, immediate action noted and any follow up action required. The completed for each incident/accident with immediate unplanned, or data is linked to the organisation's benchmarking programme action noted and any follow up action required. The data untoward events and this is used for comparative purposes. Minutes of the is linked to the organisation's benchmarking programme including service quality meetings, staff meetings and peer review meeting reflect and this is used for comparative purposes. Minutes of shortfalls in order to a discussion of benchmarking results. Ten incident/accident the quality meetings, staff meetings and peer review identify forms were reviewed for January 2015. All demonstrated meeting reflect a discussion of benchmarking results. opportunities to clinical follow up by a registered nurse. Quality Indicators - The incident/infection analysis tool and quality indicator improve service Analysis and corrective action plan policy (284) includes and corrective action plan is well utilised at Parkwood to delivery, and to objective ' corrective actions will be identified and implemented assist with analysis and plan improvements to service identify and in response to increases or adverse trends in monthly resident delivery. When benchmarking results are above the manage risk. incidents and infection rates. normal, for example: Falls were up in July in the rest home, a CAP was completed which resulted in GP and physiotherapy reviews of those residents falling frequently, toolbox talks for staff and review to ensure residents on Vitamin D. This increase in falls also generated CAP for manual handling and managing challenging behaviours.

Criterion 1.2.7.5 CI Parkwood has a comprehensive annual education schedule The annual education programme includes two or three which is adhered to and records of attendance for all staff are in-service sessions monthly. The service is also A system to kept. Several education sessions are compulsory and all staff proactive around implementing toolbox talks for staff as a identify, plan, are expected to attend. Education topics and information is result of incidents, complaints, feedback, observations, facilitate, and also displayed on the communication board for staff that are not benchmarking results and internal audits. The following record ongoing able to attend to read. Toolbox talks held on a regular basis toolbox talks have been provided in 2014 (but not limited education for and staff been encouraged to participate. 95% of care staff to); a) Observations, recordings and reporting change, service providers to have gained the national certificate qualification with the support b) Accident/incident reporting, c) falls prevention and provide safe and of two on site assessors. Caregivers with RN qualifications bruising, d) Ebola, e) buddy system and allocation of effective services to from other countries are supported to complete BUPA or CPIT residents, f) wound management, g) uridome use, h) consumers. CAP course for Registered Nurses. All caregivers have nutrition and hydration, i) increased number of falls - commenced the external palliative care training course which deteriorating health of residents, j) supervision of high

Bupa Care Services NZ Limited - Parkwood Rest Home & Hospital Date of Audit: Page 21 of 23 will be completed in 2015, all complete the nine modules. falls risk residents, k) medication management to avoid Caregivers interviewed were proud of this additional training errors, l) post mortem care, m) basic cares, n) grooming, and palliative care qualification and the support they receive for o) laundry care, p) preparation for audit, q) clinical education from the facility and Bupa. Weekly education is documentation and responsibility. Education was also provided and staff interviewed report the sessions are provided in relation to residents on individual contracts invaluable, relevant and well attended. 100% of staff are trained and their specific needs. Completed education is in the Personal Best programme with 87% at gold level and captured on electronic spread sheet, easily identifying three achieving legend status. All new staff are commenced on attendance and capturing those ‘non-attenders.’ Weekly this programme as part of their orientation. Six RN’s have packages are displayed of various training topics for staff completed the Bupa Leadership Development programme with not able to attend the relevant training. Records kept of the remaining qualified staff scheduled to undertake this. staff that have read and signed sessions. Night RN takes responsibility for delivering night education The service are involved in CDHB NEtP programme for 2nd sessions for night staff. A quality improvement initiative year, they are the first BUPA facility in Southern Region to trial was established Feb 2014 around upskilling caregivers the programme. Parkwood has on-going placement for CPIT and registered nurses around palliative and end of life Nursing Students practical training and also Hagley Education care. The evaluation of this quality initiative included (but programme for Pre-Health Nursing Studies. RNs described not limited to) positive feedback from staff, residents and attending external education e.g. DHB/ other providers. The relatives. Clinical manager is involved in the quality team, and all are involved in peer review with the DHB Gerontology nurse specialist CM involved in ACP programme. The RN’s are supported to undertake post-graduate study. The facility manager has prepared her PDRP portfolio for expert level assessment.

Criterion 3.5.7 CI Infection control data is collated monthly and reported to the The service has continued to undertake a number of Quality and Health and Safety meeting. The meetings include initiatives as a result of infection surveillance data to Results of the monthly IC report. Infections are documented on the reduce infection numbers. IC stats were discussed at surveillance, Infection monthly register. The surveillance of infection data RN/EN meetings and corrective actions were conclusions, and assists in evaluating compliance with infection control practices. implemented when infections increase. Incident/infection specific The IC Programme is linked with the Quality Management - analysis tool was utilised to assist with identifying recommendations Programme. Quality Improvement initiatives are taken and trends. A QIP has been developed and a toolbox talk to assist in recorded as part of continuous improvement. Documentation provided to staff and residents around nutrition fluids/ achieving infection covers a summary, investigation, evaluation and action taken. appropriate clothing. Infection stats, trends and reduction and There is a number of internal audits completed including (but education are regularly provided via noticeboards and prevention not limited to) standard precautions, environmental hygiene meetings to staff, residents and relatives. Other toolbox outcomes are acted (cleaning, laundry, kitchen and nursing) and food service. talks provided to staff included (but not limited to); upon, evaluated, scabies, shingles, warm weather, increase in fluid and reported to requirements. Benchmarking with other Bupa facilities relevant personnel and graphing of data is undertaken monthly. The and management infection control co-ordinator has completed post in a timely manner. graduate infection control management study and has been in the role for two years. There are regional teleconferences three monthly for infection control coordinators and resources available and accessible. The infection control committee which includes the infection control co-ordinator, clinical manager, an RN and caregiver from each unit, the kitchen manager and a household representative. The committee met two monthly and reported information back to the two monthly quality and risk meeting.

End of the report.

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