Waikato District Health Board - Mental Health
Current Status: 22 July 2014
The following summary has been accepted by the Ministry of Health as being
an accurate reflection of the Surveillance Audit conducted against the Health
and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and
NZS8134.3:2008) on the audit date(s) specified.
General overview
The Waikato District Health Board (DHB) Mental Health Service inpatient services
includes the Henry Rongomau Bennett Centre (adult and forensic services) and the
Mental Health Services for the Older Person, located in the new Older Persons
Rehabilitation Service facility. As well as providing mental health and addictions
services to the population of the greater Waikato area (population 373,220) the
forensic services are provided for the Midland Region of five district health boards
(DHBs): Lakes; Bay of Plenty; Taranaki; and Waikato, with a total population of
806,972.
Audit Results as at 22 July 2014
Consumer Rights
There is a focus on the service user throughout the Waikato DHB Mental Health
Service, including an awareness of, and accessible information about, the Health
and Disability Commissioner’s Code of Health and Disability Services Consumers’
Rights (the Code).
A number of new systems have been introduced to promote contemporary models of
care with an example being the introduction of a range of approaches to reduce the
need for seclusion. These have been successful with a marked reduction in the rate
of seclusion over the past 12 months.
Privacy is managed respectfully as confirmed by the service users interviewed. One
area for improvement is in the Mental Health Service for Older Persons whereby a
medical staff ward round was observed to be occurring in the lounge area rather
than in the designated room. The previous request to improve the adult acute
intensive care environment has been resolved effectively with much improved
natural lighting and the inclusion of a gym area.
Cultural needs assessments are evident in service users’ records and there are well
integrated cultural approaches to service delivery. The chaplaincy service is also
readily available.
There are accessible information display areas on the wards providing service users
and their families with a wide range of useful material. The role of the consumer
development advisor is well integrated and involved in service developments. One
of these developments is the introduction of a debriefing process held with the
service user post a seclusion event to assist with learning and implementation of any
required changes.
A previous requirement to allow a forensic service user to bring food on to the ward
has now been met. Service user’s rights to independence and dignity are seen to be
respected.
The service is increasingly striving to engage directly with service users and families
to enhance their open disclosure practice and this is demonstrated in the effective
processes implemented in response to complaints. An area requiring improvement
is for staff to document in the clinical record once they have informed the service
user/family of an error made during service delivery.
Organisational Management
The Waikato DHB Mental Health Service has been systematically implementing the
priorities in the Strategic Plan 2009-2014. This includes a new leadership structure
and an outcomes framework with a focus on performance. The service also has a
kaupapa ‘to earn a reputation as a service people trust with their loved one’s care’
with six key outcomes: building leadership; being culturally responsive; supporting a
recovery approach; providing safe and effective services; being transparent and
trustworthy; and being a service that is sustainable and efficient. Each of these
outcomes have indicators and measures assigned.
There has been considerable quality improvement activity since the 2012 audit. This
includes the transformational ‘time for change programme’ which has resulted in
positive culture change with many staff saying they are proud to work in the service
and have never been happier in their jobs. A major initiative has been
implementation of the productive wards/releasing time to care activity on the wards.
This is delivering positive results.
The systems for managing complaints, incidents and adverse events are responsive
with investigation completed in a timely manner and corrective actions followed up.
An area requiring improvement is around updating of policies with 35% being
overdue for review. The document control matters raised at the 2012 audit have
been addressed.
There is increasing involvement in clinical audit and a structured schedule is being
developed which will integrate with the Waikato DHB-wide clinical and systems audit
schedule. There is good progress with implementing the risk management system
including the assessment and decision making matrix. The service is now awaiting
the introduction of an information system to advance the Waikato DHB quality and
risk programme. This will be a Midland region-wide solution.
Job descriptions and performance appraisals align to the service direction and
values, including the accountabilities, competencies and expected performance for
each role. Performance appraisals are up to date and have learning and
development objectives linked to the service direction and future requirements. The
recruitment processes are robust. There is a recently produced comprehensive
orientation document which provides an overview of the ‘big picture’ of the service
along with service specific information.
Mandatory training is identified, provided and documented. There are minimal staff
vacancies. The credentialing system is well developed with comprehensive
documentation.
In the past four months the CAP PLAN system has been implemented to monitor
and predict bed occupancy rate. The service is also using ‘levels of observation’ to
help define the acuity level in each ward and matching service user need to the ward
staff profile and skill mix. There is a daily bed management meeting to assess
demand and jointly agree the best allocation of staff resource to meet need.
The clinical record is integrated with examples sighted of the input of other specialty
teams into the record. Improvements are required to ensure signing, dating and
indicating the designation of the practitioner are included for all entries in the record.
Continuum of Service Delivery
Two service users’ journeys were followed through the service; one at the Inpatient
Mental Health Service for Older People (MHSOP) and one at the Adult Acute
Inpatient Mental Health Service. Reviewing the services delivered included additional
sampling of files and service user and family interviews.
Services are delivered by a multidisciplinary team that consist of inpatient and
community based health professionals and support personnel. This ensures
consistent service delivery and a seamless transition from the inpatient to the
community treatment setting and vice versa. Service provider responsibilities and
time frames for each service delivery component were defined in a documented
pathway. Each service user has a treatment/care plan that reflects their identified
needs. Recovery progress is monitored and documented and includes discharge
planning.
Service users and families interviewed praised staff for the effort they make to
ensure information exchange and consultation about treatment occurs.
Areas requiring improvement relate to the time frames by which assessments are
required to be completed, the inclusion of identified medical needs in the treatment
plans, and the practice of permanently locking the doors of the acute wards.
The previous request to improve the service provision setting for service users over
65 years has been addressed through co-locating the MHSOP in the purpose built
Older Person’s Rehabilitation (OPR) facility. The MHSOP unit has 15 beds, four
more than previously.
The national drug chart is consistently completed to requirements. Medicines
processes are fully implemented with regular input from the pharmacist. The
medication rooms are exceptionally well arranged and maintained. Aspects of
controlled drug documentation requirements need to be improved.
Meals, including special diets are provided by a central kitchen. The menus are in
line with nutritional guidelines. Dietitians are accessible when needed. Service users
expressed satisfaction with the meals provided.
Safe and Appropriate Environment
The Henry Rongomau Bennett building has a current warrant of fitness and the
environment is appropriate for the needs of this service user group. Notably, some
aspects of facilities design directly impact on reducing the need for stringent
interventions, particularly seclusion. For example, the sensory modulation area in the
forensic service and the newly redesigned low stimulus area which is effective in
providing safe care.
The Mental Health Service for Older People moved into the purpose-built Older
Persons Rehabilitation (OPR) building a year ago and this has proven to be a vastly
better environment than previously. The OPR building now has a code compliance
certificate and the courtyard fence in the ‘OPR1’ area has been modified to make it
safe. This has been achieved without limiting the outlook of the service users. Both
of these now meet requirements raised at the verification audit of this building a year
ago. However, the over-bed hoists in OPR1, are still not operational and so the
requirement to address this remains.
Both the Henry Rongomau Bennett building and the OPR building have approved
fire evacuation plans and have up to date trial evacuations. The fire evacuation plan
for OPR1, however, requires this frail service user group to descend a flight of
external stairs outside the designated fire exit. In addition, staff on OPR1 have not
yet had advanced cardiac life support or resuscitation training. These issues
continue from the verification audit as requiring improvement.
Restraint Minimisation and Safe Practice
The Waikato DHB Restraint Advisory Committee continues to provide detailed
monitoring of restraint use. The Mental Health Service has had a sustained approach
to minimising the use of restraint and seclusion as part of its ‘time for change’
campaign. Part of this has resulted in the redeveloped restraint training resources,
now labelled Respect: restraint elimination, safe practice and effective
communication training. The emphasis lies on improved interpersonal skills
throughout the whole mental health service, not just in the inpatient areas. Related to
this is the intent to reduce and eliminate seclusion use, which is described as a
‘failure of treatment’. Data are rigorously collected and analysed to show significant
reductions in restraint and seclusion use, outstripping internally set goals.
Infection Prevention and Control
Surveillance for infections are defined. One example of an infection outbreak was
followed through. The outbreak management reviewed showed full implementation
of the required processes, containment of the outbreak and effective responses and
communication on all levels of the organisation.