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 0 1 0 0 Criteria 1 91 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
Service providers recognise and facilitate the right of consumers to advocacy/support persons of their choice. service. Education was conducted as part of the in-service education programme for staff. Staff demonstrated knowledge of advocacy processes. Standard 1.1.12: Links With Family/Whānau And Other Community Resources Consumers are able to maintain links with their family/whānau and their community. FA Families reported that they are encouraged to visit at any time, and are always welcomed. Residents are supported and encouraged to access community services with visitors, or as part of the planned activities programme. There was evidence in residents’ files that this occurs regularly. Staff were observed welcoming visitors and encouraging outings. Standard 1.1.13: Complaints Management The right of the consumer to make a complaint is understood, respected, and upheld. FA The complaints policy and associated forms meet the requirements of Right 10 of the Code. Information on the complaint process is provided to residents and families on admission and those interviewed knew how to do so. Forms are available in the facility at all times. The complaints register reviewed showed that four complaints have been received over the past year and that actions taken, through to an agreed resolution, are documented and completed within the timeframes. One complaint remains open and this is currently in the investigative process by the Health and Disability Commissioner and all requests for additional information have been responded to in a timely manner following the required process. Action plans show any required follow up and improvements have been made where possible. The facility manager is responsible for complaints management and follow up. All staff interviewed confirmed a sound understanding of the complaint process and what actions are required. Standard 1.1.2: Consumer Rights During Service Delivery Consumers are informed of their rights. FA Family and residents interviewed reported that the Code was explained to them on admission, was included as part of the admission pack, and time was allowed for them to understand the information. Nationwide Health and Disability Advocacy service information is also included in the admission pack with brochures available at the entrance and communal of the facility. Residents and families interviewed reported that they were aware of their right to access advocacy services but they had not needed to do so. Standard 1.1.3: Independence, Personal Privacy, Dignity, And Respect FA Residents and family interviewed reported that the residents are treated in a manner that shows regard for the resident's dignity, privacy and
Consumers' service delivery are evaluated in a comprehensive and timely manner. monthly reviews of care plans were occurring. Both residents and family were consulted and informed when changes are identified. This was confirmed during interviews and via the family communication forms. Information was being included in progress notes and changes were being made to interventions on care plans when indicated. Staff interviewed stated they are consulted prior to evaluations. Standard 1.3.9: Referral To Other Health And Disability Services (Internal And External) Consumer support for access or referral to other health and/or disability service providers is appropriately facilitated, or provided to meet consumer choice/needs. FA The GP arranges for any referral to specialist medical services when it is necessary. The residents’ files reviewed had appropriate referrals to other health and diagnostic services. The RN confirmed that they utilise external services as much as possible. Referrals were sighted for consultations with general medicine, pathology, dietitian and radiology services. The GP interviewed reported that appropriate referrals to other health and disability services were well managed at the service. Standard 1.4.1: Management Of Waste And Hazardous Substances Consumers, visitors, and service providers are protected from harm as a result of exposure to waste, infectious or hazardous substances, generated during service delivery. FA Staff follow documented processes for the management of waste and infectious and hazardous substances. Appropriate signage is displayed where necessary. An external company is contracted to supply and manage all chemicals and cleaning products and they also provide relevant training for staff. Material safety data sheets were available where chemicals are stored and staff interviewed knew what to do should any chemical spill/event occur. There is provision and availability of protective clothing and equipment and staff were observed using this. Standard 1.4.2: Facility Specifications Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for their purpose. FA A current building warrant of fitness (expiry date 30 June 2017) is publicly displayed. Appropriate systems are in place to ensure the residents’ physical environment and facilities are fit for their purpose and maintained. The testing and tagging of electrical equipment and calibration of bio-medical equipment is current as confirmed in documentation reviewed, interviews with maintenance personnel and observation of the environment. Efforts are made to ensure the environment is hazard free, that residents are safe and independence is promoted. External areas are safely maintained and are appropriate to the resident groups and setting. Residents confirmed they know the processes they