Major shortfalls, significant action is needed to achieve the required levels of performance Some standards applicable to this service unattained and of moderate or high risk Consumer Rights as at 15 May 2014 Includes 13 standards that support an outcome where consumers receive safe services of an appropriate standard that comply with consumer rights legislation. Services are provided in a manner that is respectful of consumer rights, facilities, informed choice, minimises harm and acknowledges cultural and individual values and beliefs. Standards applicable to this service attained. Organisational Management as at 15 May 2014 Includes 9 standards that support an outcome consumers receive services that comply with legislation and are managed in a safe, efficient and effective manner. Some standards applicable to this service partially attained and of low risk. Continuum of Service Delivery as at 15 May 2014 Includes 13 standards that support an outcome where consumers participate in and receive timely assessment, followed by services that are planned, coordinated, and delivered in a timely and appropriate manner, consistent with current legislation. Some standards applicable to this service partially attained and of low risk. Safe and Appropriate Environment as at 15 May 2014 Includes 8 standards that support an outcome where services are provided in a clean, safe environment that is appropriate to the age/needs of the consumer, ensure physical privacy is maintained, has adequate space and amenities to facilitate independence, is in a setting appropriate to the consumer group and meets the needs of people with disabilities. Standards applicable to this service fully attained. Restraint Minimisation and Safe Practice as at 15 May 2014 Includes 3 standards that support outcomes where consumers receive and experience services in the least restrictive and safe manner through restraint minimisation. Standards applicable to this service fully attained. Infection Prevention and Control as at 15 May 2014
HDS(C)S.2008 Criterion 1.3.5.2 Service delivery plans describe the required support and/or intervention to achieve the desired outcomes identified by the ongoing assessment process. PA Low There is no mention in the resident support plans for the dementia level residents of the current abilities, level of independence, deficits and as far as practicable their personal preferences, individual habits, routines and idiosyncrasies. Post Audit: The provider does not agree with this finding. To identify and ensure the resident needs are clearly identified and describe appropriate support and/or intervention to achieve the goals identified by the ongoing assessment process. 180 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 to comply with legislation, protocols, and guidelines. PA Low On review of the medication records it was observed that one general practitioner is bracketing the prescribed medications and signing off all medications with the one signature. To ensure each prescribed medication is signed off individually on the medication record by the general practitioner. 180
Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.) Criterion 1.1.3.6 (HDS(C)S.2008:1.1.3.6) Services are provided in a manner that maximises each consumer's independence and reflects the wishes of the consumer. 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.) Criterion 1.1.3.7 (HDS(C)S.2008:1.1.3.7) Consumers are kept safe and are not subjected to, or at risk of, abuse and/or neglect. 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.)
Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.) Standard 1.4.4: Personal Areas (HDS(C)S.2008:1.4.4) Consumers are provided with adequate personal space/bed areas appropriate to the consumer group and setting. ARC E3.3b; E3.3c ARHSS D15.2e; D16.6b.ii Attainment and Risk: FA Evidence: Residents have private rooms, with the exception of one shared room in the dementia suited which is shared by a couple. All rooms have adequate space for equipment and care. Residents and family members interviewed voiced no concerns regarding personal space/bed areas. Bedrooms sighted are decorated with personal items. This includes bedrooms in the dementia suite. The district health board contract requirements are met. Criterion 1.4.4.1 (HDS(C)S.2008:1.4.4.1) Adequate space is provided to allow the consumer and service provider to move safely around their personal space/bed area. Consumers who use mobility aids shall be able to safely maneuvers with the assistance of their aid within their personal space/bed area. 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.)