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 5 0 0 0 Criteria 0 95 0 4 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
documented in the residents’ file. All episodes were also reviewed by the restraint coordinator and the restraint committee. Standard 2.2.5: Restraint Monitoring and Quality Review Services demonstrate the monitoring and quality review of their use of restraint. FA The restraint monitoring and quality review occur and last completed on 14 October 2014. There is organizational level restraint meeting which was last held on August 2014. Outcomes of these reviews were documented and reported on to the clinical governance group as well as being discussed at the quality and staff meetings. Restraint audit had been completed and required improvements were implemented.
service provider levels and skill mixes in order to provide safe service delivery. wing have a 16 bed capacity each. Cleaning and laundry duties are completed by the caregivers who are multi-skilled. This is in keeping with providing a homely environment with minimal people entering and exiting the homes on various tasks. Interviews with a RN, five caregivers stated that staffing is adequate to meet the needs of residents. that the psychogeriatric unit and hospital unit can share a RN between 10pm -7am only if the service is under 50 beds. There is not always a RN rostered in the hospital as well as the PG unit during the day/evening. 30 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 There is a standing order list signed by the GP’s for hospital residents only. The standing order form does not have a specified time for review. The maximum number of doses for each standing order is not specified on the standing order form. Ensure the standing order from complies with the Ministry of Health standing order guidelines 2012. 90 days Criterion 1.3.6.1 The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed and desired outcomes. PA Low Frequent falls physiotherapy assessments are carried out as required. Falls risk and interventions are well documented in care plans that include sensor mats, hip protectors, adequate hydration, clutter free environment and good fitting shoes. Mobility and handling plans are reviewed regularly to guide the staff in the safe transfer of residents. Frequent fallers are reviewed by the MDT team. Reduction of psychotropic medications are reduced to minimise side effects and monitored by the GP, geriatrician and psychiatric team. The dietitian visits monthly and completes any resident reviews due and attends to any referrals received for residents with weight loss and initiates special authority for supplements and liaises with the cook regarding any resident dietary changes/requirements. Residents are weighed monthly or more frequently as per the weight Hospital resident long term care plan reviewed August 2014 documents a need for referral to dietitian. There is no evidence of a dietitian referral or visit. Ensure dietitian referrals are initiated and followed-up. 90 days