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 with other Ryman facilities. Staff receive on-going training in infection control. Summary of Attainment CI FA PA Negligible PA Low PA Moderate PA High PA Critical Standards 2 48 0 0 0 0 0 Criteria 3 98 0 0 0 0 0 UA Negligible UA Low UA Moderate UA High UA Critical Not Applicable Pending Not Audited Standards 0 0 0 0 0 0 0 0 Criteria 0 0 0 0 0 0 0 0 Corrective Action Requests (CAR) Report Code Name Description Attainment Finding Corrective Action Timeframe (Days) Continuous Improvement (CI) Report Code Name Description Attainment Finding HDS(C)S.2008 Standard 1.1.8: Good Practice Consumers receive services of an appropriate standard. CI HDS(C)S.2008 Criterion 1.1.8.1 The service provides an environment that encourages good practice, which should include evidence-based practice. CI The Ryman Accreditation Programme (RAP) is directed from head office and directs quality and risk management activity that facilities are required to complete on a monthly basis. Review of documentation and interview with staff indicate Ernest Rutherford is implementing the RAP programme as prescribed. Policies and procedures cross-reference other policies and appropriate standards. There is a RAP committee at Ryman head office that reviews best practice, legislation, standards, research, and policy and procedure review. All changes made to
Standard 1.3.4: Assessment (HDS(C)S.2008:1.3.4) Consumers' needs, support requirements, and preferences are gathered and recorded in a timely manner. ARC D16.2; E4.2 ARHSS D16.2; D16.3d; D16.5g.ii Attainment and Risk: FA Evidence: The following personal needs information is gathered during admission (but not limited to): personal and identification and next of kin, ethnicity and religion, current and previous health and/or disability conditions, medication and allergies, activities of daily living, equipment needs, family/whanau support, activities preferences, food & nutrition information and mental function. Risk assessment tools and monitoring forms are available and implemented to assess level of risk and required support for residents including (but not limited to); a) water low pressure area risk assessment, b) skin integrity, c) three day continence assessment, d) coombes falls risk, e) dietary profile/nutritional needs screening f) pain/Abbey scale assessment g) physiotherapy assessment. h) Behavioural assessment i) wound assessment and enabler/restraint assessment (as applicable). Assessments are reviewed six monthly or when there is a change to condition. ARC E4.2; Three resident files reviewed included an individual assessment that included identifying diversional, motivation and recreational requirements. E4, 2a Challenging behaviours assessments are completed. Behaviour nursing care are in place. Criterion 1.3.4.2 (HDS(C)S.2008:1.3.4.2) 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. Attainment and Risk: FA Evidence: Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)