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 (FA) 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 40 0 0 4 1 0 Criteria 0 88 0 0 4 1 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
master roster was sighted, and covered all shifts; however there were some blanks on this due to there being insufficient staff available. Rosters that covered three weeks prior to the audit, as well as the current one, were reviewed and all shifts had been filled in with a name. Caregivers generally have their own shifts, which were stated to be usually four per week with some doing split shifts. The morning shifts have five carers rostered on, as do the afternoons. There are three caregivers rostered on the night shift. A pattern of double shifts and certain staff working multiple days, which has the potential to compromise the safety of residents’ care were noted and has been raised for corrective action. A care co-ordinator, or a senior caregiver, is rostered on each morning or afternoon shift as often as possible. A registered nurse, and/or an enrolled nurse works each day and if one of these is on leave the other will work seven days. In the absence of the registered nurse, the regional manager (who is also a reigstered nurse), reportedly provides additional cover for the enrolled nurse. An on-call system is in place to ensure caregivers have access to clinical support. The enrolled nurse is going into the facility out of hours to assist staff who do not necessarily have the required skills, such as for the administration of medicines. An example of this occurred during the audit. Roles and responsibilities of on-call staff require review. Commitments to date for the registered nurse has meant some registered nurse duties, such as the review of incident reports and the updating of care plans, have not occurred as required and the expectations of her role requires review. The issues for corrective action were discussed with the owner and the regional manager during the audit. To mitigate the risks they developed and documented a time framed plan of action prior to the end of the audit that was for immediate implementation. The plan included immediate use of registered nurse cover from another local facility and their specific roles were listed. Immediate advertising for registered nurses and for caregivers was on the list as was the need to increase the number of night staff who are medication competent. Standard 1.2.9: Consumer Information Management Systems FA There was no personal or private resident information on public display during the audit. The resident's name and date of birth and national health index (NHI) are used as the unique identifier on all resident's information