zilongwang/ReadingBank huggingface dataset:
Specific results for criterion where 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 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 1.3.3.3 Each stage of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer. PA Low Medical assessment by the GP occurs within 48hrs of admission, and residents are reviewed monthly by the GP, or three monthly if the GP has deemed the resident stable and able to be reviewed three monthly. Three of seven residents’ files reviewed, are being reviewed by the GP three monthly, and there is no verification or documentation the GP had deemed the resident stable and not requiring monthly reviews. Evidence sighted supports the resident being stable at this time. Interviews and documentation verifies GP input is accessed when residents are unwell. Residents are not always reviewed monthly by the GP. No evidence was sighted to verify the GP supports the resident does not require monthly reviews. Evidence is provided to verify the GP supports any resident not requiring monthly visits. 180 days Criterion 1.3.5.2 Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the PA Low reviewed evidenced all residents have an individualised lifestyle care plan. The assessment findings in consultation with the resident and/or family/whanau, informs the care plan and assists in identifying the required support the resident requires from care staff, to meet their goals and desired outcomes. Progress notes, activities notes, updated All residents have lifestyle care plans, however these are not always updated to describe the required support needed, nor evidence service integration to enable a Lifestyle care plans describe the support the resident requires to achieve the desired outcomes.
Specific results for criterion where corrective actions are required 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 Rating Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.4.2.1 All buildings, plant, and equipment comply with legislation. PA There is a building warrant of fitness (BWOF) displayed for the existing rest home building. The new build has yet to gain the Certificate of Public Use/ Code of Compliance. There is a process in place in the current rest home that will be implemented in the new building for ongoing maintenance and calibration of equipment and electrical testing and tagging. The service has a planned and reactionary maintenance programme, with the building maintained in an adequate condition to meet the needs of the residents. The maintenance log notes the area of work required and is signed off when the work is completed. The hot water temperatures are monitored monthly and readings comply with legislation. The dementia unit will have security fencing to allow residents to wander freely in a secure environment (also refer to 1.4.2.6). The Code of Compliance/Certificate of Public use has not yet been received. The furnishings have not been installed. Ensure the required council certifications and the furnishings are in place prior to occupancy. to occupancy days Criterion 1.4.2.4 The physical environment PA The floor furnishing and interior decoration and fit out are not yet complete. The new build has wide corridors and doors to enable safe mobility, with or without mobility aids. The fit out of the new build has not yet been completed. Ensure the fit out of the building is
assessed needs, and desired outcomes. and residents interviewed all stated the care was very good. behaviours, high falls risk and the use of a bed cradle for a chronic ulcer. This resident did not have a care plan in place for care following a recent fall; iii) One resident with dementia did not have updated instructions for low mood and nutritional needs included in the care plan; and iv) The service did not have short-term care plans in place for wounds. The dementia unit wound care documentation did not include timely reviews/evaluations of wounds. One wound chart included the wound care for three wounds, not allowing for differentiation between wounds. One resident in the dementia unit did not have a wound care plan in place for a wound. Of the eight hospital wounds, four did not document evaluations/reviews according to timeframes and two wound charts included three wounds on each not allowing for differentiation between wounds. ii) and iii) ensure that resident lifestyle support plans reflect resident need iv) Ensure that care plans are documented for wounds, that wound care plans are completed for each wound and that they are evaluated according to timeframes 60 days
Criterion 1.4.2.1 All buildings, plant, and equipment comply with legislation. PA Low A Certificate of Public Use has been issued for a section of the new building and is valid until 26 November 2016. A Code of Compliance is required prior to occupation. As the hot water system has not yet been turned on in the area to be used for hospital level care, there is no available evidence that the temperature of the hot water is safe. A courtyard in the middle of the new buildings is not yet complete, although is well underway. The contractors provided an assurance this would be finished and safe for use prior to the hand- over date. The manager and owner advised that the remaining equipment and furniture is due to arrive on 19 September 2016. There is no Building Warrant of Fitness or Code of Compliance available and nor is there evidence that hot water temperatures are safe. Although well underway, the courtyard in the middle of the new buildings is not yet complete and at the time of audit the equipment and furniture had not yet arrived. A Code of Compliance is provided and a record of hot water temperatures is provided to demonstrate the building, plant and equipment meet legislative requirements. There is evidence that the internal courtyard has been completed and that the furniture and equipment is in place. Prior to occupancy days
Specific results for criterion where 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 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 these is a message “no data to display” then no continuous improvements were recorded as part of this of this audit. No data to display End of the report.
control education will be provided to all service providers as part of their orientation and as part of the ongoing in-service education programme. 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 11 0 6 0 0 0 Criteria 0 30 0 7 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
Organisational management Anglican Care Waiapu is the governing body and is responsible for the service provided at this facility. Anglican Care Waiapu have a strategic plan that includes the vision, purpose, mission statement, core values and passion of the organisation, this is used in the development of a facility specific business plan. The facility is managed by an experienced and suitably qualified manager, supported by a clinical manager who is a registered nurse. There is an organisation wide quality and risk management plan and systems are in place for monitoring the services provided, including regular monthly reporting by the facility manager through to the governing body. Quality and risk includes an annual calendar of internal audit activity, monitoring of complaints and incidents, health and safety, infection control, restraint minimisation and resident and family satisfaction. Collection, collation and analysis of quality improvement data is occurring and is reported to the quality and staff meetings, with discussion of trends and follow up where necessary. Reporting occurs to the organisation’s clinical quality and compliance manager, who undertakes benchmarking among the organisation’s facilities. Meeting minutes, graphs of clinical indicators and benchmarking results are displayed. Adverse events are documented on incident forms. Corrective action plans are being developed and implemented where required. Formal and informal feedback from residents and families is used to improve services. Actual and potential risks and hazards are identified, mitigated and are up to date. A suite of organisation wide policies and procedures cover the necessary areas, with some facility specific policies in place. Regular reviews occur and presently some policies are under review and out for discussion. The human resources management policy, based on current good practice, guides the system for recruitment and appointment of staff. An orientation and staff training programme ensures staff are competent to undertake their role. An annual training plan is in place and a record of ongoing training is in staff files. Regular individual performance review are undertaken. Staffing levels and skill mix meet contractual requirements and the needs of residents. Senior staff are on call after hours and at weekends.
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 1 46 0 1 2 0 0 Criteria 1 97 0 1 2 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
Criteria 0 98 0 2 1 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
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.) Standard 1.3.8: Evaluation (HDS(C)S.2008:1.3.8) Consumers' service delivery plans are evaluated in a comprehensive and timely manner. ARC D16.3c; D16.3d; D16.4a D16.3c; D16.4a Attainment and Risk: FA Evidence: Evaluation of resident care is undertaken on a daily basis and documented in the progress notes. If any change is noted it is reported to the RN, who may contact the GP if requested. Family/whanau are kept informed of changes. Formal care plan evaluations are conducted by the RN at least six monthly or as needs change. Evaluation measures the degree of achievement or response of each resident related to their goals six monthly. Where progress is different from expected, the service responds by initiating changes to the service delivery plan. When a resident is not responding to the services or interventions, changes are initiated to the care plan. Evidence of evaluation is sighted in files reviewed. Resident and family interviews verify they are included and informed of all care plan updates and changes. The ARRC requirements are met. Criterion 1.3.8.2 (HDS(C)S.2008:1.3.8.2) Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome. 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.)
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
Consumers' service delivery plans are evaluated in a comprehensive and timely manner. reviewed resident’s files when the desired outcomes are not met. Short term care plans evidenced the resident’s response to treatment after the treatment regime is completed. Standard 1.4.2: Facility Specifications Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for their purpose. FA is a current building warrant of fitness displayed. There have been no changes to the layout of the building since the last audit or last evacuation (February 2016). Standard 3.5: Surveillance Surveillance for infection is carried out in accordance with agreed objectives, priorities, and methods that have been specified in the infection control programme. FA The infection surveillance programme is appropriate for aged care. The service uses standardised definitions to identify infections that are based on residential care setting best practice. Infection data is collected and analysed monthly. The data is externally benchmarked on a quarterly basis. There are low numbers of infections, with five months in the reporting period 2015 and 2016 where there have been no infections. When trends or common possible causative factors are indicated, actions are implemented to reduce the reoccurrence of the infection. The actions implemented are discussed at the staff meetings. Staff interviewed reported that they are informed of infection rates at monthly staff meetings and through compiled reports. Standard 2.1.1: Restraint minimisation Services demonstrate that the use of restraint is actively minimised. FA The service demonstrated that the use of restraint is actively minimised. There are no residents using restraint; three residents use an enabler. The restraint register is current. The policies and procedures have good definitions of restraints and enablers. Staff demonstrated good knowledge regarding restraints and enablers. The previous area for improvement in 2.2.1 has been fully implemented in practice.
and prevention outcomes are acted upon, evaluated, and reported to relevant personnel and management in a timely manner. hand hygiene. Hand hygiene education was completed which included a visual hand washing audit of this unit resulting in staff achieving a compliance result of 55%. As a result of the additional cases being identified and extra precautions activated again the ‘5 moments of hand hygiene’ audit was developed and implemented which includes focus not only on hand hygiene but the availability and utilisation of personal protective equipment by staff. Several audits were completed over the following months with varied results, resulting in further education, new equipment (hand gel dispensers), and staff were encouraged to ensure that all protective equipment and resources were restocked regularly in all areas and utilised. The ‘5 moments of hand hygiene’ audit in May 2016 had a compliance of 37%. Following further discussions with staff the audit was again completed achieving compliance of 100% for handwashing. In regards to stocking of equipment the audit findings were 73.5%. At time of audit there have been no further cases of MRSA identified within the unit. Ongoing education continues and is discussed at all relevant meetings. End of the report.
The infection control surveillance programme is appropriate to the size and complexity of the service. Results of surveillance are acted upon, evaluated and used to determine infection control activities, resources and education needs within the facility. This included audits of the facility, hand hygiene and surveillance of infection control events and infections. The service engages in benchmarking with other Summerset facilities. 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) 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 14 0 4 0 0 0 Criteria 0 37 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) Standards 0 0 0 0 0 Criteria 0 0 0 0 0
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) 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 48 0 1 1 0 0 Criteria 0 99 0 1 1 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
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 11 0 4 0 0 0 Criteria 0 29 0 6 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
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) 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 11 0 4 0 0 0 Criteria 0 29 0 6 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
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 50 0 0 0 0 0 Criteria 2 99 0 0 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
Infection control experts are available and can be consulted by the infection control coordinator when required. The infection control coordinator has attended annual infection control updates. 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) 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 2 1 0 0 Criteria 0 90 0 2 1 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
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 programme and its content and detail are appropriate for the size, complexity and degree of risk associated with the service. The infection control officer (clinical manager) is responsible for coordinating/providing education and training for staff. The infection control officer is supported by the Bupa quality and risk team. The infection control manual outlines a comprehensive range of policies, standards and guidelines, training and education of staff and scope of the programme. 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 with other Bupa facilities. Staff receive ongoing training in infection control. 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 44 0 1 0 0 0 Criteria 0 92 0 1 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
days a week with time recently adjusted to work in the dementia unit between the hours of three and five or six in the afternoon to support residents who have difficulty settling and eating at this time. An activities plan is documented for each day/week/month and displayed in each area, that is, one for residents in the rest home and one in the dementia unit. A lot of focus for residents is the provision of individual activities as needs of the groups vary from day to day and between areas. Activities include: physical; mental; spiritual and social aspects of life, to improve and maintain residents’ wellbeing. During the onsite audit, activities included: residents going for an outing; physical activities and one-on-one activities. Residents and family confirm they are satisfied with the activity programmes. One family member for example described how their family member was engaged despite their decline in abilities and their need to sleep more. On admission, the activities coordinator completes a recreation assessment for each resident. Each resident has an individualised plan with a monthly activity review completed and a daily log of attendance. Residents in the dementia unit have a 24-hour activity care plan documented that links to the long term care plan for managing challenging behaviours. New residents have assessments and plans completed in line with completion of the interRAI assessment (refer 1.3.8). Standard 1.3.8: Evaluation Consumers' service delivery plans are evaluated in a comprehensive and timely manner. PA Low There is a policy that outlines review of care plans and the link to interRAI. All residents have a current care plan however in the past there has been a lack of review of care plans. A plan is in place to ensure that care plans are reviewed six monthly. There are frequent reviews completed by the general practitioner for each resident. All reviewed had the need for a three monthly medical review to be completed however each of the eight resident files reviewed indicated that the resident had been reviewed by a general practitioner at least one or two monthly with some who had deteriorated reviewed weekly or as required. A review of resident
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 45 0 0 0 0 0 Criteria 2 91 0 0 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
Audit Team Lead Auditor XXXXX Hours on site 4 Hours off site 2 Other Auditors hours on site Total hours off site Technical Experts Total hours on site Total hours off site Consumer Auditors Total hours on site Total hours off site Peer Reviewer XXXXX 1 Sample Totals Total audit hours on site 4 Total audit hours off site 3 audit hours 7 Number of residents interviewed Number of staff interviewed 3 Number of managers interviewed 3 Number of residents’ records reviewed 3 Number of staff records reviewed 4 Total number of managers (headcount) 3 Number of medication records reviewed Total number of staff (headcount) Number of relatives interviewed Number of residents’ records reviewed tracer methodology Number of GPs interviewed
Standards 0 0 0 0 0 0 0 34 Criteria 0 0 0 0 0 0 0 63 Corrective Action Requests (CAR) Report Code Name Description Attainment Finding Corrective Action Timeframe (Days) HDS(C)S.2008 Standard 1.3.12: Medicine Management Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines. PA Low HDS(C)S.2008 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 (i)Three eye ointments in use in the PG unit are not dated. (ii) One stock eye ointment in use but not named; (iii) There was two expired stock medications in the cupboard (i) and (ii) Ensure eye ointments are and named when in use; (iii) Ensure impress stock is monitored and expired medication returned to pharmacy 60 HDS(C)S.2008 Standard 1.4.2: Facility Specifications Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for their purpose. PA Low HDS(C)S.2008 Criterion 1.4.2.1 All buildings, plant, and equipment comply with legislation. PA Low The unit is in the process of refurbished for hospital/rest home residents. Ensure all renovations and refurbishments are completed Prior to occupancy Continuous Improvement (CI) Report Code Name Description Attainment Finding
Specific results for criterion where 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 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 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 Finding Criterion 1.1.8.1 The service provides an environment that encourages good practice, which should include evidence-based practice. CI The service has identified that clinical reporting to appropriate meetings has been a great improvement since last audit. They have implemented facility, clinical managers and training coordinator reports for the monthly quality meetings. The service is currently developing KPIs within the Arvida Group. However, they are still to set group benchmarking but Ilam have continued with internal benchmarking with five other facilities. The service is proactive in implementing quality improvements. The following have been implemented (but not limited to) dietary needs, residents diversional therapy in apartments, needle stick injuries – prevention, H&S injury The service identified an increase in challenging behaviours in February (four) and March (five) in 2016. There were staff incidents reported in relation to challenging behaviours with two in March and four in June 2016. In July 2016, the service implemented an action plan to reduce the number of challenging behaviours. There was a team approach to implement the “Cressy goals” including improved communication and mentoring and training sessions for all staff. There were regular meetings held with the clinical manager, charge nurse, diversional therapist and caregivers to identify individual resident de-escalation techniques. All behaviour assessments, behaviour charts and care plans were reviewed to ensure all triggers and alternative de-escalation strategies were documented to inform staff of early warning signs and interventions that were successful. Meaningful activities to reduce behaviours have been introduced
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
Consumers receive services of an appropriate standard. Staffing policies include pre-employment and the requirement to attend orientation and ongoing in-service training. Residents and families interviewed spoke positively about the care and support provided. Staff interviewed had a sound understanding of principles of aged care and stated that they feel supported by the management team. Staffing policies include pre-employment and the requirement to attend orientation and ongoing in-service training. The service has implemented an activity exercise group that has reduced falls. Standard 1.1.9: Communication Service providers communicate effectively with consumers and provide an environment conducive to effective communication. FA Residents interviewed stated they were welcomed on entry and given time and explanation about the services and procedures. Accident/incidents, complaints procedures and the policy and process around open disclosure alerts staff to their responsibility to notify family/next of kin of any accident/incident and ensure full and frank open disclosure occurs. Incident/accidents forms reviewed had documented evidence of family notification or noted if family did not wish to be informed. Relatives interviewed confirmed that they are notified of any changes in their family member’s health status. A residents/relatives meeting occurs every three months and issues arising from the meeting are communicated to staff. Any issues raised from these meetings are investigated by the village manager and there was evidence of implemented corrective actions. Interpreter services are available as required. Standard 1.2.1: Governance The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers. FA Wendover Rest Home is owned and operated by the Arvida Group. Wendover provides care for up to 54 residents at rest home level care including providing rest home level care across 11 serviced/studio apartments. Three resident rooms were not in use, two were due to earthquake damage and one was converted into the clinical manager’s office. On the day of the audit, there were 47 residents in total, 43 residents in the rest home (including two residents on respite care) and four residents in serviced/studio apartments. All long-term residents were admitted under the aged related residential care contact (ARRC). The village manager has over 14 years’ experience working in the aged care sector and has been in the position for six months. She is supported by a clinical manager/RN who has been in the role for four
Restraint is only used as a last resort when all options have been explored. An assessment, approval and monitoring process with regular reviews occurs. Staff receive training at orientation and thereafter annually. Staff demonstrated a sound knowledge and understanding of the restraint and enabler processes. Similarly, the review of residents’ files and associated documents for the Restraint Approval Group confirmed that the organisation’s systems are implemented and these standards are being met. Infection prevention and control The infection prevention and control programme, led by an experienced and appropriately trained infection control coordinator, aims to prevent and manage infections. There are terms of reference for the infection control committee which meets monthly. Specialist infection prevention and control advice is accessed from the district health board (DHB), microbiologist, infectious diseases physician, and group clinical advisory committee. The programme is reviewed annually. Staff demonstrated good principles and practice around infection control, which is guided by relevant policies and supported with regular education. Aged care specific infection surveillance is undertaken, analysed, trended, benchmarked and results reported through all levels of the organisation. Follow-up action is taken as and when required. Summary of attainment The following 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 49 0 1 0 0 0 Criteria 0 99 1 1 0 0 0
record ongoing education for service providers to provide safe and effective services to consumers. the clinical manager identified that compulsory training had not been occurring as required by the organisation’s policies. She developed a spreadsheet identifying gaps in compulsory training and annual competencies, scheduled training sessions, has followed up on quality improvement trends with information sessions and additional education, and addressed a significant proportion of the deficits. However approximately one third of staff are yet to complete all compulsory annual training and competencies. assessments, as planned. 180 days
was completed in the past 12 months. The notification related to a pressure injury in July 2016. Standard 1.2.7: Human Resource Management FA There are organisational policies to guide recruitment practices and documented job descriptions for all positions. Appropriate recruitment documentation was seen in the eight staff files (one clinical manager, one hospital coordinator/RN, one RN, two caregivers, one education coordinator, one administrator/health and safety officer and one activities coordinator) reviewed. Performance appraisals are current in all files reviewed. Interviews with caregivers inform that management are supportive and responsive. All newly appointed staff complete general induction and role specific orientation. Health practitioners and competencies policy outlines the requirements for validating professional competencies. A register of practising certificates is maintained. is an annual training plan aligned with the TeamRyman programme that is being implemented. Staff ‘catch up’ folders contain education content for staff to read and sign if they were unable to attend training. There is an aged care education coordinator/RN to support staff working towards the national standards. Ryman ensures RNs are supported to maintain their professional competency including attending the journal club meetings and external education. Six of seventeen RNs (including the clinical manager) have completed their InterRAI training. Seventeen out of twenty care assistants who are employed in the dementia care unit have completed their dementia specific unit standards. Three care assistants are in progress to complete their dementia training and have commenced work within the last 12 months. Completion of induction programme and required dementia standards are required to be monitored and reported monthly to head office as part of the TeamRyman programme.
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 13 0 2 0 0 0 Criteria 0 33 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
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 48 0 2 0 0 0 Criteria 1 98 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
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 where 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 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 Finding Corrective action required and timeframe for completion (days) Criterion 1.2.9.9 All records are legible and the name and designation of the service provider is identifiable. PA Low All residents’ files sampled were legible and entries were signed and dated by the registered nurse, caregiver, doctor or other person making the entry. All files sampled had correction fluid in the care plans. Five of five resident files sampled (two rest home and three hospital level) has entries blocked out with correction fluid. Ensure that entries in resident files meet required guidelines and do not use correction fluid. 90 days
Criteria 0 59 0 0 1 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
The infection prevention and control programme includes policies and procedures to guide staff. The infection prevention and control team holds integrated meetings with the health and safety team. A monthly infection control report is completed, trends identified and acted upon. Benchmarking occurs and a six-monthly comparative summary is completed. Summary of attainment The following 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 1 14 0 1 1 0 0 Criteria 2 36 0 1 1 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
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 prevention and control management programme, inclusive of surveillance, is appropriate for the nature of the service. The infection control coordinator is a registered nurse. Monthly surveillance data is collated and findings are reported at staff, management and organisational level. Corrective actions are put in place if an upward trend is identified. Benchmarking occurs against 26 other organisational groups as well as by an outside contracted company. 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 1 0 0 0 Criteria 0 38 0 1 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
Standard 2.1.1: Restraint minimisation Services demonstrate that the use of restraint is actively minimised. FA The service restraint minimisation and safe practice policy meets the requirements of the standard. Clear definitions of an enabler and a restraint are available to guide staff. On the days of the audit the register reviewed listed eight residents using an enabler and 27 residents using a form of restraint. The resident records reviewed contained evidence that assessment for use has been conducted prior to use, alternatives had been tried, approval granted by the restraint committee and valid consent obtained by either the resident or their representative. There was evidence of ongoing monitoring and review of each restraint intervention. Enabler use was voluntary. The clinical manager of the hospital is the restraint co-ordinator. The restraint coordinator maintains a list of all staff training and the relevant competency test completed annually by all staff. Feedback from staff was positive about training and knowledge on the service`s restraint philosophy and approach to restraint minimisation. All processes are clearly understood.