Infection prevention and control The infection control programme and its content and detail are appropriate for the size, complexity and degree of risk associated with the service. The infection control co-ordinator (clinical manager) is responsible for coordinating education and training for staff. The infection control co-ordinator has attended external training. There are a suite of infection control policies and guidelines to support practice. Appropriate training of staff is included as part of the programme. The infection control co-ordinator uses the information obtained through surveillance to determine infection control activities and education needs within the facility. This includes audits of the facility, hand hygiene and surveillance of infection control events and infections. 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 42 0 3 0 0 0 Criteria 0 90 0 3 0 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
manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines. medication charts sampled are identified with photographs and allergy status. The prescribing of regular and PRN medications meets legislative requirements. general practice phones the facility following monthly INR and informs the dose, this is written on a monitoring form and administered by staff. There is no prescription signed by the general practitioner. It is noted this was being addressed during the audit. b) one medication chart (2012 entry) had a verbal order recorded taken by a registered nurse from a consultant psychiatrist that has not been signed by a medical practitioner. medication aligns with best practice. 60 days Criterion 2.1.1.4 The use of enablers shall be voluntary and the least restrictive option to meet the needs of the consumer with the intention of promoting or maintaining consumer independence and safety. PA Low The restraint minimisation policy aims to ensure the safety of residents, service providers, and others through minimising preventable and avoidable risks throughout restraint. These procedures include assessment of least restrictive option, consent, monitoring and evaluation. The clinical nurse manager is the restraint coordinator. Education is provided to staff around restraint, and challenging behaviours. The service currently has no clients using restraint or enablers although environmental restraint is in place via key pad entry at the outside gate. Environmental restraint is in place, limiting the freedom of movement for a select group of residents with dementia. Ensure restraint processes are implemented for those residents whose freedom of movement is restricted. 90 days