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 7 11 0 0 0 0 0 Criteria 9 32 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
Attainment against the Health and Disability Services Standards The following contains the results of all the standards assessed by the auditors at this audit. Depending on the services they provide, not all standards are relevant to all providers and not all standards are assessed at every audit. Please note that Standard 1.3.3: Service Provision Requirements has been removed from this report, as it includes information specific to the healthcare of individual residents. Any corrective actions required relating to this standard, as a result of this audit, are retained and displayed in the next section. For more information on the standards, please click . For more information on the different types of audits and what they cover please click . Standard with desired outcome Attainment Rating Evidence Standard 1.1.13: Complaints Management The of the consumer to make a complaint is understood, respected, and upheld. CI The number of complaints received each is reported monthly to care services via the facility benchmarking spread sheet. There is a complaints flowchart. D13.3h. The complaints procedure is provided to resident/relatives at entry and prominent around the facility on noticeboards. A complaint management record is completed for each complaint. A record of all complaints per month is maintained by the facility using the complaint register. Documentation including follow up letters and resolution demonstrates that complaints are well managed. . Discussion with residents and relatives confirmed they were provided with information on complaints and complaints forms. 2014 and 2015 to date complaints were reviewed. All were well documented including investigation, follow up letter and resolution. The service continues to exceed the standard around implementing learning’s from complaints. Standard 1.1.8: Good Practice CI Bupa Fergusson continues to exceed the required standard around good practice. Evidence-based practice is evident, promoting and encouraging good practice. Registered nursing staff are available seven days a week, 24
the service and staff training was completed early in March 2014 around this. Criterion 2.2.5.1 Services conduct comprehensive reviews regularly, of all restraint practice in order to determine: (a) The extent of restraint use and any trends; (b) The organisation's progress in reducing restraint; (c) Adverse outcomes; (d) Service provider compliance with policies and procedures; (e) Whether the approved restraint is necessary, safe, of an appropriate duration, and appropriate in light of consumer and service provider feedback, and current accepted practice; (f) If individual plans of care/support identified alternative techniques to restraint and demonstrate restraint evaluation; (g) Whether changes to policy, procedures, or guidelines are required; and (h) Whether there are additional education or training needs or changes required to existing education. CI There are Bupa policies around the completion of restraint assessments and monitoring. This is benchmarked with other Bupa facilities. Individuals’ approved restraint is reviewed at least two monthly through the clinical and quality meeting and as a multi-disciplinary review with family/EPOA involvement. Restraint usage throughout the organisation is also monitored regularly and is benchmarked. The organisation and facility are proactive in reducing restraints. Currently there are no residents on restraints in the dementia unit or rest home. No one has been restrained in the rest home since April 2011. There are seven hospital level residents on restraint. Restraints used do not currently include bed rails but lap belts and one low/low bed. There are four hospital level residents currently using enablers. There is full family/EPOA consultation documented around the use of any restraint and enablers. Alternatives and risks are explored and restraint is only used as a last resort. Regular falls assessments and toileting regimes are used, as well as assessments by physiotherapists, training and staff competencies. The facility have worked hard to reduce the number of residents’ on restraint and maintain this status through the two monthly meetings, handovers, on-site training/toolbox talks with care givers and registered nurses. Staff talked about the need to reduce restraints and were able to identify risks involved and the need to monitor residents’. End of the report.