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 36 0 7 2 0 0 Criteria 0 83 0 7 3 0 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
control programme and meet the needs of the organisation. Standard 3.3: Policies and procedures 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. FA The infection control policies and procedures have been developed by the organisation and reflect current accepted good practice. The service has access to good practice resources from a specialist infection prevention and control consultancy and benchmarking services. The policies are appropriate to the services offered by the facility. Staff demonstrated knowledge and understanding of standard precautions and stated they undertake actions according the policies and procedures. Staff were observed to be washing hands and using personal protective equipment appropriately. Standard 3.4: Education The organisation provides relevant education on infection control to all service providers, support staff, and consumers. FA The infection control coordinators/managers conduct most of the infection control education. are some visiting specialists who provide infection control education and self-directed learning packages. The infection control coordinators/managers demonstrated current knowledge in infection prevention and control. They attended ongoing education on current good practice in infection prevention and control. As required, infection control education can be conducted informally with residents, such as reinforcement of infection control practices with washing hands, blowing noses, cough etiquette and personal hygiene when assisting with toileting. Standard 3.5: Surveillance Surveillance for infection is carried out in accordance with agreed objectives, priorities, and methods that have been specified in the infection control programme. PA Low The service uses standardised definitions applicable to aged care that are provided by the external benchmarking service to identify infections. The type of surveillance undertaken is appropriate to the aged care service with data collected on urinary tract infections, influenza, skin infections and respiratory tract infections. There is monthly collection and collation of the types and numbers of infection in both the rest home and hospital services, though there was limited evaluation of this data (refer to 3.5.7). The data is also benchmarked on a quarterly basis with an external benchmarking service. The perspective provider intends to maintain the current infection control systems, with additional reporting of the statistics and analysis to their organisational wide governance/quality team. The outcomes are fed back to the staff at the next staff meeting. The infection surveillance records include the review and analysis of an outbreak that
the contractual requirement for admission assessments to be undertaken by an RN. Criterion 1.3.3.3 Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer. PA Low Residents in the rest home are routinely reviewed by the GP three monthly as evidenced in all files reviewed. was no sighted documentation to evidence the GP has verified the resident is stable and suitable for three monthly reviews. During interview, the GP was unaware that all residents had to be verified by the GP as stable and suitable for three monthly rather than monthly reviews. Each stage of service provision meets timeframes, with the exception of GP reviews in the rest home. Evidence is provided that GPs review residents within the required timeframes to meet their needs. 90 days 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 The initial care plan of two residents (one hospital and one rest home) recently admitted, had no documentation verifying comprehensive assessment of skin integrity, nutrition, behaviour, or pressure injury risk. residents (one rest home and two hospital) who had fallen had an initial assessment completed following the fall, however, no documentation verifying ongoing monitoring is recorded. There was no evidence sighted on the day of audit to verify monitoring had occurred. InterRAI assessments are not updated within the six month time frame if residents’ needs change. All files reviewed had no evidence of cultural needs being assessed, or a consideration to cultural needs requiring attention in care planning. Residents have their needs identified through a variety of information sources including the assessment process; however, assessment documentation is not always consistent with the residents’ required needs. Provide evidence residents are comprehensively assessed on admission and reassessed when there is a change in condition. 90 days Criterion 1.3.5.2 PA Moderate Service delivery describe the required support to achieve the desired outcomes; Service delivery plans are inconsistent and do not Provide evidence that service delivery
Service delivery describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process. however this is not always consistent. Two residents recently admitted (one hospital and one rest home), had documentation to verify their needs in relation to activities of daily living, however no management strategies were documented to manage skin integrity needs, cultural needs, or pressure injury risk (refer 1.3.3.3 and tracer 2). A diabetic resident had no plan of care to manage the resident’s diabetic needs; however the kitchen was providing the resident with a diabetic diet and the residents blood sugar levels were being monitored, as per sighted evidence. Three residents who had fallen had an initial assessment and subsequent documentation completed. Incident reports were completed and families were informed of the incident however no management strategies were documented to identify the required monitoring following the fall. No evidence was sighted monitoring occurred. A resident recently re-admitted, following a complex referral for specialist services, had an increased level of needs in relation to some aspects of care required. Not all of these had been updated in the care plan, and interviews with care staff evidenced some staff not being aware of all aspects of the care the resident required. Evidence verified the GP had been informed of any changes, as requested. A resident exhibiting episodes of challenging behaviour had documentation in the progress notes recording the episodes of challenging behaviour, however there was no management plan that captured suggested management strategies to manage the behaviour. accurately reflect the support the resident requires to meet their needs. describe the required support to achieve desired outcomes. 90 days