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 3 12 0 2 0 0 0 Criteria 4 34 0 2 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
Specific results for criterion corrective actions are required Where a standard is rated partially attained (PA) or unattained (UA) specific corrective actions are recorded under the relevant criteria for the standard. The following table contains the criterion where corrective actions have been recorded. Criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1: Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of everyday practice relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights. If there is a message “no data to display” instead of a table, then no corrective actions were required as a result of this audit. Criterion with desired outcome Attainment Rating Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.2.8.1 There is a clearly documented and implemented process which determines service provider levels and skill mixes in order to provide safe service delivery. PA Low The staffing levels policy is the documented rationale for determining staffing levels and mixes for safe service delivery. The hospital has an RN on duty 24/7 who covers the psychogeriatric unit. The clinical manager/RN is an additional RN two days per week. Staffing requirements on night duty meet contractual requirements. Registered nurse staffing levels do not meet the requirements for a hospital and a psychogeriatric unit. There are two registered nurses on duty for two mornings a week only (clinical manager and a registered nurse). For five mornings a week there is one registered nurse on duty and for afternoon shifts there is one RN on duty to cover both the psychogeriatric and hospital units. There is one RN on duty overnight. The risk is considered to be low due to low resident numbers currently in the hospital unit. There has been ongoing communication between the provider and DHB/HealthCERT regarding the RN staffing levels in this small facility. Ensure there is 1. A registered nurse rostered on duty in the hospital between the hours of 7am and 10pm 2. A registered rostered on duty in the psychogeriatric unit between the hours of 7am and 10pm 3. If the total occupancy is below 50, there is one registered
Specific results for criterion a continuous improvement has been recorded As well as whole standards, individual criterion within a standard can also be rated as having a continuous improvement. A continuous improvement means that the provider can demonstrate achievement beyond the level required for full attainment. The following table contains the criterion where the provider has been rated as having made corrective actions have been recorded. As above, criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1 relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights If, instead of a table, these is a message “no data to display” then no continuous improvements were recorded as part of this of this audit. Criterion with desired outcome Attainment Rating Audit Evidence Audit Finding Criterion 1.2.1.1 The purpose, values, scope, direction, and goals of the organisation are clearly identified and regularly reviewed. CI is a strong focus within the organisation to promote independence, to value the lives of residents and staff and this is supported by the vision and values statement of the organisation. The vision for the organisation is: 'to create a loving, warm, and homely atmosphere where each person is supported to experience each moment richly'. The service aims to achieve the vision by promoting the uniqueness of each person, acknowledging the immense value of each person and by promoting openness, honesty and integrity. Philosophy of care incorporates: 1) the 'best friend' approach - acceptance, belief in the person, forgiveness, listening, and laughter; 2) families/whanau become part of the community and are involved in their loved one’s care. They are encouraged to share their knowledge of their loved one to build trust and to promote honesty and openness; 3); small homely units provides residents with a stable and familiar environment; 4); staff are acknowledged as people with skills and abilities who have the potential to be a positive impact on residents, families and their work teams; 5) ensuring that residents can continue with their hobbies, interests and participate in meaningful and purposeful activities and 6) the philosophy of care is to promote participation in life activities, promote physical, healthy and emotional wellness. This is well demonstrated at Millvale House Levin. Staff attend “best friends” training sessions and in-service on the service philosophy. Wellness support advisor coordinates sessions