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. Infections are reported by staff and residents and monitored through the infection control surveillance programme by the infection control officer (the enrolled nurse). There are infection prevention and control policies, procedures and a monitoring system in place. Training of staff and information to residents is delivered regularly. Infections are monitored and evaluated for trends and discussed at staff meetings. 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 41 0 4 0 0 0 Criteria 0 89 0 4 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)
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 their 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 Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.2.9.1 Information is entered into the consumer information management system in an accurate and timely manner, appropriate to the service type and setting. PA Low Morning and afternoon shift document the time that progress notes are written, however the night shift only document ‘nocte’. The shift do not document the time progress notes are written. Ensure that the time of entry is documented for all progress notes. 90 days Criterion 1.3.12.1 A medicines management system is implemented to manage the safe and appropriate prescribing, dispensing, administration, review, storage, disposal, and medicine reconciliation in order to comply with legislation, protocols, and guidelines. PA Low The prescribing of medications is completed on the medication chart by the GP. The medication charts were legible and signed by the GP. All ‘as required’ medications had indications for use. One resident a household remedy, which was not prescribed ‘as required’. There was no evidence of a GP verbal order. The signing sheet identified the resident had Ural sachets which were not prescribed on the medication sheet. Ensure household remedies are prescribed as required or a verbal GP order is taken and recorded. 30 days