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.
HDS(C)S.2008 Standard 1.2.3: Quality And Risk Management Systems The organisation has an established, documented, and maintained quality and risk management system that reflects continuous quality improvement principles. PA Low HDS(C)S.2008 Criterion 1.2.3.8 A corrective action plan addressing requiring improvement in order to meet the specified Standard or requirements is developed and implemented. PA Low There is limited evidence of resolution of issues documented. Document evidence of resolution of issues when these arise. 180 HDS(C)S.2008 Standard 1.2.7: Resource Management Human resource management processes are conducted in accordance with good employment practice and meet the requirements of legislation. PA Low HDS(C)S.2008 Criterion 1.2.7.5 A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers. PA Low Four of the files reviewed do not include a current annual performance appraisal. Ensure that all staff have an annual performance appraisal as per policy. 180 HDS(C)S.2008 Standard 1.3.3: Service Provision Requirements Consumers receive timely, competent, and appropriate services in to meet their assessed needs and desired outcome/goals. PA Low
HDS(C)S.2008 Criterion 1.3.3.1 Each of service provision (assessment, planning, provision, evaluation, review, and exit) is undertaken by suitably qualified and/or experienced service providers who are competent to perform the function. PA Low There is insufficient evidence that each stage of service provision is completed by a suitably qualified person in the rest home. For example a number of assessments in the rest home have no signature of the person completing them, and one file sampled had the assessments completed by a student enrolled nurse. Provide evidence that service delivery is completed by a suitably qualified person (in the rest home). 90 HDS(C)S.2008 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 There is insufficient evidence that time frames for service delivery are consistently maintained. Provide evidence that all timeframes for service delivery are maintained as required. 90 HDS(C)S.2008 Standard 1.3.6: Service Delivery/Interventions Consumers receive adequate and appropriate services in order to meet their assessed needs and desired outcomes. PA Low HDS(C)S.2008 Criterion 1.3.6.1 The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes. PA Low Not all current and interventions are documented in care plans. Provide evidence that all current needs and interventions are documented in care plans. 90 HDS(C)S.2008 Standard 1.3.8: Evaluation Consumers' service delivery plans are evaluated in a comprehensive and timely manner. PA Low
HDS(C)S.2008 Criterion 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. PA Low There is insufficient evidence that care plan evaluations are documented, consumer focused or indicate the degree of achievement towards interventions and outcomes. Fully document resident evaluations. 90 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 Moderate 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 Moderate Transcribing is sighted in six out of six medication records sighted in the hospital. (ii) There are two examples of individually prescribed medication being used as ward stock. Discontinue transcribing. (ii) Discontinue using individually prescribed medication for ward stock. 7 HDS(C)S.2008 Criterion 1.3.12.3 Service providers responsible for medicine management are competent to perform the function for each stage they manage. PA Moderate Medication competency is not observed in the rest home during the audit. Provide evidence that all staff are competent to administer medication. 30 Continuous Improvement (CI) Report Code Name Description Attainment Finding