zilongwang/ReadingBank huggingface dataset:
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) 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 2 13 0 1 1 0 0 Criteria 3 37 0 1 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
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 communicate effectively with consumers and provide an environment conducive to effective communication. Evidence of communication with family/whanau is recorded on the family/whanau communication record, which is held in the front of each resident’s file. Accident/incident forms have a section to indicate if next of kin have been informed (or not) of an accident/incident. Ten accident/incident forms that were reviewed across the rest home, hospital and dementia unit identified family are kept informed. Five relatives interviewed (one with a relative in the rest home, one with a relative in the hospital and three with relatives in the dementia unit) stated that they are kept informed when their family member’s health status changes. An interpreter policy and contact details of available interpreters is available. Interpreter services are used where indicated. The information pack is available in large print and is read to residents who require assistance. Non-Subsidised residents are advised in writing of eligibility and the process to become a subsidised resident should they wish to do so. The residents and family are informed prior to entry of the scope of services and any items they have to pay that are not covered by the agreement. Standard 1.2.1: Governance The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers. FA Bupa Avondale is a Bupa residential care facility, situated in Avondale, Auckland. The service currently provides care for up to 67 residents at hospital, rest home and dementia levels of care. On the day of the audit there were 26 hospital level residents, 25 rest home residents and 15 dementia level residents. On 26 July 2013, HealthCERT notified the provider of the approval of 11 beds for rest home or hospital level care. The auditors were requested to determine the suitability of these beds when onsite for the facility’s next audit. Based on auditor inspections, review of staffing, equipment and interviews with the care home manager and staff, these eleven rest home level beds have been determined by the auditors to be suitable for either rest home or hospital level care. Four of the eleven beds were filled with hospital level residents at the time of the audit. A vision, mission statement and objectives are in place. Annual goals for the facility have been determined, which link to the overarching Bupa strategic plan.
reception, but residents were not personally provided with copies of these. Criterion 1.2.9.9 All records are legible and the name and designation of the service provider is identifiable. PA Low Residents’ progress are updated at least daily and more frequently when clinically indicated. The majority of the names and/or the designations of the service providers making those entries were illegible in the five clinical records reviewed. The name and designation of service providers making entries into the resident’s clinical file are not consistently legible and/or the designation is not identifiable. The name of every service provider making entries into residents’ records is legible and their designation identifiable. 180 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 The controlled register contained evidence of six monthly stocktakes. The required weekly stock count of medication in the controlled drug register had not been undertaken since November 2014. The required weekly stock-count of medications in the controlled drugs register has not been undertaken on a regular basis as required. Weekly stock counts of medications in the controlled drugs register are undertaken. 90 days
Restraint minimisation and safe practice Includes 3 standards that support outcomes consumers receive and experience services in the least restrictive and safe manner through restraint minimisation. Standards applicable to this service attained. Not required to be audited. Infection prevention and control 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. There are implemented infection control policies and procedures. Surveillance activities of individual incident of infections occur. All infections are recorded in the electronic data base system and monitored by the Presbyterian Support Central office. 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)
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 3 12 0 1 0 0 0 Criteria 4 34 0 1 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
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 1 42 0 2 0 0 0 Criteria 1 90 0 2 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
A number of shortfalls that require specific action to address Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk 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 General overview of the audit Melrose Park Home & Hospital (Oceania) can provide care for up to 87 residents. This certification audit was conducted against the Health and Disability Service Standards and the service contract with the district health board. The process included the review of policies, procedures and residents and staff files, observations and interviews with residents, family, management, staff and a medical officer. Improvements are required to privacy for residents sharing and initial medical assessments for new residents. Consumer rights Includes 13 standards that support an outcome 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. Some standards applicable to this service partially attained and of low risk. Staff are able to demonstrate an understanding of residents' rights and obligations. This knowledge is incorporated into their daily work duties and caring for the residents. Residents are treated with respect and receive services in a manner that considers their
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 14 0 3 1 0 0 Criteria 0 39 0 3 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
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 47 0 3 0 0 0 Criteria 0 98 0 3 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
The facility is heated by a combination of electricity and gas appliances and has good ventilation. The outdoor provide suitable furnishings and shade for residents’ use. Restraint minimisation and safe practice 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. The service has restraint minimisation policy and procedures in place which reflect safe restraint use. Staff undertake bi-annual education related to restraint and verbalise knowledge and understanding of the requirements should restraint be required. At the time of audit Park Rest Home is restraint free. Documentation and staff interviews confirmed no restraint or enablers are in use. Infection prevention and control 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. There is a documented and implemented infection control programme which is appropriate to the service. The plan and outcomes are reviewed annually. Infection prevention and control policies and procedures are clearly documented and implemented to minimise risk of infection to residents, staff and visitors. The policies reflect current accepted good practice and are readily available for staff.
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
Where progress is different from expected, the service responds by initiating changes to the service delivery plan. Policy states that short term care plans are used for issues that can be resolved, such as infections. One of the residents’ reviewed in detail has had several infections resulting in antibiotic therapy but these are not identified on a care plan. It is identified in progress notes. Wound care plans clearly indicate changes required and larger wounds have pictorial evidence of the healing process. residents’ files reviewed, where this would have been appropriate. to the use of short term care plans and that all intervention changes are shown on the resident’s care plan. 180 days
Other Auditors XXXXXX hours on site 8 Total hours off site 4 Technical Experts hours on site Total hours off site Consumer Auditors Total hours on site Total hours off site Peer Reviewer XXXXXX 1 Sample Totals Total audit hours on site 16 Total audit hours off site 9 Total audit hours 25 Number of residents interviewed 6 Number of staff interviewed 11 Number of managers interviewed 2 Number of residents’ records reviewed 6 Number of staff records reviewed 5 Total number of managers (headcount) 2 Number of medication records reviewed 12 Total number of staff (headcount) 64 Number of relatives interviewed 6 Number of residents’ records reviewed using tracer methodology 2 Number of GPs interviewed 1
Criteria 0 38 0 2 1 0 0 UA Negligible UA Low UA Moderate UA High UA Critical Not Applicable Pending Not Audited Standards 0 0 0 0 0 0 0 34 Criteria 0 0 0 0 0 0 0 60 Corrective Action Requests (CAR) Report Code Name Description Attainment Finding Corrective Action Timeframe (Days) HDS(C)S.2008 Standard 1.1.9: Communication Service providers communicate effectively with consumers and provide an environment conducive to effective communication. PA Low HDS(C)S.2008 Criterion 1.1.9.1 Consumers have a right to full and frank information and open disclosure from service providers. PA Low Four of 11 incident forms sampled do not have evidence on the incident form or in the progress notes that family have been informed of the incident. Ensure family are informed of all incidents. 180 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 Moderate 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 and desired outcomes. PA Moderate One of six files sampled did not have the risk assessments completed within the required time frame Two of six files sampled did not have detailed interventions in the care plan for identified needs. One resident using a lap belt (enabler) did not have a risk assessment or consent form completed for the use of the lap belt. Two of three restraint monitoring forms sampled had at least one Ensure that all risk assessment required on admission are completed within the required time frames. Ensure all care plans have detailed interventions to manage identified needs and risks. Ensure all residents using enablers have the required risk assessments and consents completed. Ensure that all residents restraints have the required 90
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 9 0 6 0 0 0 Criteria 0 24 0 11 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
staff are yet to be employed, a fire drill or training around the fire evacuation procedure has not occurred Criterion 1.4.7.3 Where required by legislation there is an approved evacuation plan. PA Low Fire and emergency management is detailed in the Summerset at Karaka emergency manual. Fire drills and training are scheduled to take place during orientation week prior to opening. The Fire Evacuation scheme has not yet been approved by the New Zealand Fire Service The fire evacuation scheme has not yet been approved by the New Zealand Fire Service. Provide evidence that the NZFS has approved a fire evacuation scheme for Summerset at Karaka care centre. 30 days Criterion 1.4.7.5 An appropriate 'call system' is available to summon assistance when required. PA Low A new call bell system has been installed throughout the facility. The call system involves an individual pager system, which alerts staff when a resident activates a call bell. Call bells are situated in resident rooms, ensuite, dining/lounge rooms in care apartments, in the communal dining and lounge areas of level one and level two. The call bell system is yet to be activated. Call bell system is in place throughout the care centre however, this is yet to be activated. Ensure that the call bell system is fully functioning throughout the care centre. Prior to occupancy days
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 2 42 0 6 0 0 0 Criteria 3 90 0 8 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
Specific results for criterion where corrective actions are required Where a standard is rated partially attained (PA) or unattained (UA) specific corrective actions are recorded under the relevant criteria for the standard. The following table contains the criterion where corrective actions have been recorded. Criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1: Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of their everyday practice relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights. If is a message “no data to display” instead of a table, then no corrective actions were required as a result of this audit. Criterion with desired outcome Attainment Rating Audit Evidence Finding Corrective action required and timeframe for completion (days) Criterion 1.1.13.1 The service has an easily accessed, responsive, and fair complaints process, which is documented and complies with Right 10 of the Code. PA Low Five complaints received for 2015 evidence that appropriate follow up and response was initiated within the expected time frames. Outcomes from investigations have included staff feedback, staff training and performance management where required. Toolbox talks have been initiated with staff to reduce incidence of repeat complaints. A resident interviewed advised that follow up on a written complaint had not been provided. It was identified that the complaint had been misplaced on the manager’s desk and this was addressed during the audit. One written complaint from June 2015 has not been responded to, as advised by the complainant. Ensure that all complaints are responded to within service policy timeframes. 60 days Criterion 1.2.7.5 A system to identify, plan, facilitate, and record ongoing education for service PA Low Certification: The clinical manager maintains a competency spreadsheet for all staff. Education sessions are provided at least weekly in the form of face to face in-service sessions, self-directed learning, took box talks, Certification: Two caregivers who work in the psychogeriatric unit have not completed the required dementia unit standards. Both have been Certification: Ensure that all care staff who work in the psychogeriatric unit/s have completed the required dementia
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
Specific results for criterion where a continuous improvement has been recorded As well as whole standards, individual criterion within a standard can also be rated as having a continuous improvement. A continuous improvement means that the provider can demonstrate achievement beyond the level required for full attainment. The following table contains the criterion where the provider has been rated as having made corrective actions have been recorded. As above, criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1 relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights If, instead of a table, these is a message “no data to display” then no continuous improvements were recorded as part of this of this audit. Criterion with desired outcome Attainment Rating Evidence Audit Finding Criterion 1.1.8.1 The service provides an environment that encourages good practice, which should include evidence-based practice. CI The service is committed to continuous quality improvement. Quality improvement plans (QIPs) are developed for any deficits identified as of a result of concerns/complaints, internal audits, below average quality indicators and suggestions for improvement. Malvina Major has participated in two research projects within the last year being; 1) Pharmac pilot in the use of ‘as required’ antipsychotic medication in dementia, to reduce incidence of challenging behaviours, and 2) Massey University pilot of the whole body vibration exercise intervention to reduce the number of falls. Two QIPs implemented; 1) palliative care focus and 2) bowel management have been evaluated and evidence positive changes in nursing practice. 1) The service identified an improvement required around end of life care following a clinical review of palliative care residents. Palliative/end of life care was included as a key focus for the 2014 village objectives that would see Malvina Major as the provider for best palliative care for residents and their families. A meeting was held with the management team and key stakeholders including the general practitioner (GP) and hospice clinical educators to develop strategies and goals that would improve palliative care over the 24-hour period. Village and care centre residents involvement and feedback sought on the project through regular meetings. Palliative care discussion is held at all service meetings. The following have been implemented over the period April 2014 to April 2015:
A number of shortfalls that require specific action to address Some standards applicable to this service partially attained and of medium or high risk and/or unattained and of low risk 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 28 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 28 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. Standards applicable to this service attained. Continuum of Service Delivery as at 28 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 medium or high risk and/or unattained and of low risk. Safe and Appropriate Environment as at 28 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 attained. Restraint Minimisation and Safe Practice as at 28 May 2014 Includes 3 standards that support outcomes consumers receive and experience services in the least restrictive and safe manner through restraint minimisation. Some standards applicable to this service partially attained and of low risk. Infection Prevention and Control as at 28 May 2014
Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 choose 30, for 6 months choose 180, etc.) Criterion 1.2.7.3 (HDS(C)S.2008:1.2.7.3) The appointment of appropriate service providers to safely meet the needs of consumers. 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 1.2.7.4 (HDS(C)S.2008:1.2.7.4) New service providers receive an orientation/induction programme that covers the essential components of the service provided. Attainment and Risk: FA Evidence: Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 choose 30, for 6 months choose 180, etc.)
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 2 48 0 0 0 0 0 Criteria 4 97 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
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 areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented. PA Low Meeting minutes and completed internal audits reviewed do not consistantly provide documented evidence that: corrective actions are being monitored for their effectiveness; are being signed off as completed; and the timeframe and person/s responsible for the corrective action is recorded. Provide documented evidence that corrective actions are being monitored and signed off as being completed and that the timeframe and person/s responsible for the corrective action/s is being consistantly recorded. 180 HDS(C)S.2008 Standard 1.2.4: Adverse Reporting All adverse, unplanned, or untoward events are systematically recorded by the service and reported to affected consumers and appropriate their family/whānau of choice in an open manner. PA Low
HDS(C)S.2008 Criterion 1.2.4.2 The service provider understands their statutory and/or regulatory obligations in relation to essential notification reporting and the correct authority is notified where required. PA Low A sentinel event was not notified to Oceania support office until 20 days after the initial accident with injury was reported to the clinical leader. Provide confirmation that staff are aware of their responsibilities in relation to reporting of essential notifications. 90 HDS(C)S.2008 Standard 1.3.3: Service Provision Requirements Consumers receive timely, competent, and appropriate services in order to meet their assessed needs and desired outcome/goals. PA Moderate 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 Moderate Neurological observations are not consistently recorded for un-observed falls. Staff members to complete neurological observations for all falls to ensure the safety of residents at all times. 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
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. Infection prevention and control policies include guidelines on prevention and minimisation of infection and cross infection. Infection control is an agenda item at staff meetings with surveillance of infections occurring. 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 43 0 2 0 0 0 Criteria 0 91 0 2 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
Standards 1 41 0 1 2 0 0 Criteria 3 87 0 1 2 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
Principle 7 – Removing medication administration during dining room service enhancing the dining experience for residents. First person care plans and inclusion of photos. In depth ’Loneliness, Helplessness and Boredom’ support plans. Surveying residents ‘Domains of Wellbeing’ and implementing action plans to further enhance outcomes. Principle 8 – Resident involvement in senior team meetings and recreation planning. Resident satisfaction survey results reflect significant in the following areas: activities and lifestyle (69% (2014) and 86% (2015); medical and therapy services (74% 2014) and 85% (2015); communication and social involvement (69% (2014) and 83% (2015); maintaining community contact (79% (2014) and 88% 2015). The managers attribute these positive results to the implementation of the Eden Alternative. Criterion 1.2.3.6 Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers. CI There are quality and risk management processes in place. The programme includes infection control, quality improvement, service delivery, resident rights, managing service delivery, emergency and human resources. The service completes an internal audit for each area, which results in a report that identifies criteria covered and achievements, a general summary of the audit results, key issues for improvement and an action plan for resolution. It was identified over a two-quarter period that falls had increased, peaking in September 2013 at 118%. The facility planned an improvement project to reduce falls through a number of strategies. The initiatives and strategies led to positive outcomes with a continued decline in fall rate over a 5-quarter period and performing well below the industry benchmark. QPS Benchmarking and the PSC Quality and Innovation awards have recognised this achievement. The last two quarters have seen a slight rise in which directly related to one resident who is falling frequently. A number of initiatives have been implemented for this resident to assist in maintaining their level of independence (link to tracer). This was also confirmed when reviewing accident and incident forms for the facility.
Executive summary of the audit Introduction This section contains a summary of the auditors’ findings for this audit. The information is grouped into the six outcome areas contained within the Health and Disability Services Standards: consumer rights organisational management continuum of service delivery (the provision of services) safe and appropriate environment restraint minimisation and safe practice infection prevention and control. As well as auditors’ written summary, indicators are included that highlight the provider’s attainment against the standards in each of the outcome The following table provides a key to how the indicators are arrived at. Key to the indicators Indicator Description Definition Includes commendable elements above the required levels of performance All standards applicable to this service fully attained with some standards exceeded No short falls Standards applicable to this service fully attained Some minor shortfalls but no major deficiencies and required levels of performance seem achievable without extensive extra activity Some standards applicable to this service partially attained and of low risk
Includes 6 standards that support an outcome 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. The infection prevention and control programme includes policies and procedures to staff. A registered nurse is the infection prevention and control officer. A monthly infection control report is completed and forwarded to head office for analysis and benchmarking. A six monthly comparative summary is completed. Surveillance data is used to determine infection control activities and education needs at the facility. The service has had one outbreak since the previous audit. 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 0 15 0 2 0 0 0 Criteria 0 39 0 2 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
The outcomes, and/or goals of consumers are identified via the assessment process and are documented to serve as the basis for service delivery planning. provided for residents. Assessments are undertaken by registered nurses all who are allocated to specific residents in the home. The number of residents are divided evenly between all registered nurses to ensure all reviews are undertaken to meet the needs of the residents. A schedule is being developed for the interRAI assessments to be completed but has not been implemented as yet. The memory loss house has full occupancy. A placement issue of two residents was observed. The two residents are placed in memory loss house during the daytime. One resident (hospital level) has already been assessed as requiring memory loss services (no bed is available) and the other (rest home level) is currently better managed in this care setting more appropriately than in the rest home/hospital section of the home and needs to be re-assessed. employed, have completed the required interRAI training therefore not all residents admitted to this facility have had an interRAI assessment completed in a timely manner. Two residents are being cared for in the memory loss house during the day. One resident has been assessed but there are no beds available in this service. The other resident is currently assessed as rest home level of care but is currently being managed in the dementia service for safety purposes. Reassessment is required to ensure appropriate placement for this resident. the required interRAI training, and that all residents undergo an interRAI assessment on admission, and for the six monthly review process and subsequent reviews as necessary. Ensure appropriate assessments are able to be validated, as well as documented information from the WDHB to evidence these reviews have occurred. 180 days Criterion 2.2.2.1 In assessing whether restraint will be used, appropriate factors are into consideration by a suitably skilled service provider. This shall include but is not limited to: PA Low Policies and procedures are in place for restraint minimisation but do not include aspects of environmental restraint. During the audit a hospital resident and a rest home resident were sighted to be in the dementia unit. This is environmental restraint. The Ensure environmental restraint is covered in restraint minimisation policies and procedures. Ensure
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
Specific results for criterion where corrective actions are required Where a standard is rated partially attained (PA) or unattained (UA) specific corrective actions are recorded under the relevant criteria for the standard. The following table contains the criterion where corrective actions have been recorded. Criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1: Service providers demonstrate knowledge and understanding of consumer rights and obligations, and incorporate them as part of their everyday practice relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights. If there is a message “no data to display” instead of a table, then no corrective actions were required as a result of this audit. Criterion with desired outcome Attainment Rating Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.3.12.6 Medicine management information is recorded to a of detail, and communicated to consumers at a frequency and detail to comply with legislation and guidelines. PA Low Twelve medication charts were reviewed; all were correctly labelled including the resident name, photo and any known allergies. Medication signing sheets all documented that the administering nurses were signing for medication on administration. All medication charts reviewed identified that the GP had seen the reviewed the resident three monthly. As required (PRN) medications included indications for use and all administration signing sheets were completed. Of the twelve medication charts reviewed, two had two different types of chart for the same resident. It was not clear as to the medications that were to be given at any given time. Ensure there is consistent charting to aid clarity of medication charts 60 days Criterion 1.3.5.2 PA Low Lifestyle support plans are in place for all residents and document care plan i) One hospital resident (tracer) with documented weight loss, did not have interventions for weight loss management documented in the care plan, and i-v) Ensure that resident lifestyle support plans include nursing
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
evaluation, review, and exit) is undertaken by suitably qualified and/or experienced service providers who are competent to perform the function. office of the activities coordinators. Reviews and evaluations are being done six monthly, mostly by a registered or enrolled nurse. The activities coordinators are highly skilled in the delivery of the activities programme, and link with a local group of diversional therapists and activities coordinators on a monthly basis; however they have not undertaken the related training that would ensure the personal goals are reported on, reviewed and evaluated as required by the standard. undertaken relevant training and the progress reporting and evaluations of activities goals are mostly being written by nursing staff and do not necessarily reflect the personal goals. accountable for assessment and evaluation of social, diversional and motivational recreation programmes. 180 days
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 1 20 0 1 1 0 0 Criteria 2 47 0 1 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
Criterion 1.3.3.1 (HDS(C)S.2008:1.3.3.1) Each stage 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. 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 1.3.3.3 (HDS(C)S.2008:1.3.3.3) 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. 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 1.3.3.4 (HDS(C)S.2008:1.3.3.4) The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate. Attainment and Risk: FA Evidence:
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
legislation, protocols, and guidelines. requirements that these reviews are recorded on the medication chart. The service has commenced addressing this, and has now got a medication chart template that has a section for the three monthly reviews to be recorded. consistently recorded. 180 days Criterion 3.1.3 The organisation has a clearly defined and documented infection control programme that is reviewed at least annually. PA Low There was no evidence that the infection control programme has been reviewed in the past 12 months. There is a documented review of an outbreak that occurred in March 2015, this is specific to the actions implemented for the outbreak. There was no overall review of the infection control programme as a whole that has occurred within the last 12 months, which indicates that the infection control programme is meeting its goals. The infection control polices records that the review of the infection control programme is 2 yearly. The infection control coordinator’s job description records the infection control programme is required to be reviewed annually. The annual review of the infection control programme was not sighted. Provide evidence that the infection control programme is reviewed at least annually. 180 days
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 2 47 0 1 0 0 0 Criteria 4 96 0 1 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
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 14 0 1 1 0 0 Criteria 0 36 0 2 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