The restraint minimisation procedure states the purpose of restraint is 'To minimise the use of restraint providing a safe environment for residents, staff and visitors. To ensure that when restraint is practised, it occurs in a safe and respectful manner for the minimum length of time. The service currently has nine residents requiring restraint and none using enablers. Infection prevention and control Includes 6 standards that support an outcome which minimises the risk of infection to consumers, service providers and visitors. Infection control policies and procedures are practical, safe and appropriate for the type of service provided and reflect current accepted good practice and legislative requirements. The organisation provides relevant education on infection control to all service providers and consumers. Surveillance for infection is carried out as specified in the infection control programme. Standards applicable to this service fully attained. The infection control coordinator uses the information obtained through surveillance to determine infection control activities, resources and education needs within the facility. This includes audits of the facility, hand hygiene and surveillance of infection control events and infections. The service engages in benchmarking infection control data. 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 15 0 0 4 0 0 Criteria 0 36 0 3 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
to commence in the Selwyn facilities within the next month. A copy of residents nutritional profiles are sent to the main kitchen and also a copy is kept in the kitchen serveries on site. The kitchen has a comprehensive system whereby they are kept current with changing needs of the residents. The food is transported to the facility in insulated hot boxes and transferred into bain maries. Food temperatures are taken before leaving the main kitchen and upon arrival and before service. The receiving kitchen also holds some food, sandwiches, biscuits, fruit and soup. Residents are also a choice e.g. alternate meat dishes and vegetarian. There is evidence of modified diets being provided e.g. diabetic menu and further nutritional supplements. The service has a kitchen manual which includes (but not limited to); policies and procedures committed to the provision of nutritional foods; hydration needs, special dietary requirements and equipment, food safety and quality review. Fridge, food and freezer temperatures (main kitchen) are monitored twice daily and documented. Food in the chiller and freezer was covered and dated. Selwyn Heights kitchen/ serveries are spacious providing a safe working area and adequate dry storage and pantry area. All food storage items were off the floor. The kitchen area was very clean and tidy. Kitchen catering staff carry out all cleaning duties. The hot meals are delivered from the main kitchen and held in the Bain Marie until served. Hot food and fridge temperature monitoring was sighted and all temperatures within acceptable limits. There are alternative fridges that can be used if there is a temperature problem. There are alternative foods available such as salads and nutritious snacks outside normal kitchen hours. Special/modified diets and additional supplements required are provided. Kitchen staff are aware of resident’s likes/dislikes and any changes are communicated to the staff. There are special items including: lip plates and easy grip utensils to meet the assessed needs of the rest home residents. Residents can choose to have breakfast in bed or in the dining room. Staff were observed wearing correct protective clothing and safe footwear. The food service is a set agenda item at the residents meetings. There are six monthly food satisfaction surveys. Interviews with seven residents (two rest home and five hospital) overall spoke favourable about the food. Standard 1.3.5: Planning FA The initial care plan is developed from the initial assessment and identifies the areas of concern or risk as evidenced in five of six files reviewed (# link
summaries are entered into the database. Criterion 1.2.3.6 Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers. PA Low Quality and risk performance is reported across the facility meetings, through the communication book, and also to the organisation's management team is no documented evidence that quality data is reported to staff at the general staff meeting since April 2014. Ensure that all quality data is reported to all staff at the facility meetings and that this is documented. 90 days Criterion 1.2.3.8 A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented. PA Moderate summaries are entered into the database. Benchmarking reports are generated throughout the year to review performance over a 12 month period. The service continues to collect data to support the implementation of QIP's. Clinical audits completed in May and August 2014 with 93% compliance, cleaning audits completed in August and September 2014 with 93% and 83 % compliance and the annual satisfaction survey in November 2013 do not show evidence of corrective actions developed as a result of shortfalls identified. Ensure that corrective actions are developed for areas of audits/surveys that have not reached compliance. 30 days Criterion 1.3.12.5 The facilitation of safe self-administration of medicines by consumers where appropriate. PA Low Policy states that self-medication must be monitored every shift. Two of two self-medicating residents had no documentation to evidence they had been monitored Ensure that all residents have self-medication monitored and that this is documented every shift. 30 days Criterion 1.3.6.1 The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed PA Moderate Selwyn Heights provides services for residents requiring rest home and hospital of care. The care being provided is consistent with the needs of residents as evidenced in four of six files sampled. (i)One resident in the hospital (tracer) had changes in weight and neither the dietician, GP or Nurse Practitioner were notified when the weight dropped in three weeks. (ii)Two residents with a fall documented on an incident form had no clear interventions in (i), (ii), (iii) ensure that all residents have documented assessments, care plans and interventions to meet