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. Infection control management systems are in place to minimise the risk of infection to consumers, service providers and visitors. The infection control programme is implemented and meets the needs of the organisation and provides information and resources to inform the service providers. Documentation evidences that relevant infection control education is provided to all service providers as part of their orientation and as part of the on-going in-service education programme. The type of surveillance undertaken is appropriate to the size and complexity of the organisation. Standardised definitions are used for the identification and classification of infection events. Results of surveillance are acted upon, evaluated and reported to relevant personnel in a timely manner. Outbreaks are appropriately managed. 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 1 0 0 0 Criteria 4 88 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
feel supported by the nurse manager and nursing staff. There are implemented competencies for care workers and the registered nurse. There are clear ethical and professional standards and boundaries within job descriptions. The service has exceeded the required standard around good practice. Standard 1.1.9: Communication Service providers communicate effectively with consumers and provide an environment conducive to effective communication. FA Residents interviewed stated they were welcomed on entry and were given time and explanation about the services and procedures. A sample of incident reports reviewed, and associated resident files, evidenced recording of family notification following incidents and change in health status. Relatives interviewed confirm they are notified of any changes in their family member’s health status. The nurse manager and registered nurse were able to identify the processes that are in place to support family being kept informed. Non-Subsidised residents are advised in writing of their eligibility and the process to become a subsidised resident should they wish to do so. Residents and family are informed prior to entry of the scope of services and any items they have to pay for that are not covered by the agreement. The facility has an interpreter policy to guide staff in accessing interpreter services. Residents (and their family/whānau) are provided with this information at the point of entry. Families are encouraged to visit. Standard 1.2.1: Governance The governing body of the organisation ensures services are planned, coordinated, and appropriate to the of consumers. FA Walmsley House is part of the Presbyterian Support Southland (PSS) organisation. The service is one of four aged care facilities governed by the PSS trust board. The service is certified to provide rest home level care for up to 31 residents. On the days of audit there were 29 residents including two on short-term respite care, one on an ACC contract and one on a younger person with disability contract. The nurse manager is a registered nurse and maintains an annual practicing certificate. She has been in the role since November 2014 having previously worked for PSS for four years. The nurse manager is supported by a registered nurse, care staff and PSS management team, including a quality manager and the director of services for older people. Presbyterian Support Southland has an overall strategic plan and quality programme with specific quality initiatives conducted at Walmsley House. The organisation has a philosophy of care, which includes a mission statement. The nurse manager has completed in excess of eight hour’s professional development in the past 12 months.
receptionist were observed distributing percussion instruments and glockenspiels to the residents and encouraging participation in singing and dancing. Activity assessments and plans, along with initial assessments identified initial reluctance to participate in any type of activity or identified different levels of physical and/or cognitive ability. Evaluations have been completed throughout to measure effectiveness of the therapy. have been completed throughout to measure effectiveness of the therapy. On the day of audit residents were witnessed fully and enthusiastically participating in the music therapy session. The session was facilitated by the music therapist who played the guitar and sang. Music therapy provided an effective diversion, as well as increasing joint movement and reducing swelling as identified in files reviewed. There was documented evidence through assessments, evaluations and progress notes of positive improvement in moods and emotional state, social interaction with others and stimulation through rhythm, continuous movement, and vocal fluency. A monthly report is completed which identified that 90% of residents regularly attend the sessions of their own choice. Ten percent receive one on one individual therapy or choose not to attend. Participation rate has increased as residents became more aware of structure, frequency and content of the sessions. A meeting is held after the session to evaluate the effectiveness of the session and individual participation. Some of the benefits identified include; residents with dementia experience ability to recall and retain lyrics, there has been an improvement around increasing eye contact, hand-eye coordination, and facial expressions. There is increasing muscle control in face and mouth. An increase in muscle tone and movement. Documentation, resident and staff interviewed stated that the music therapy sessions appear to be enjoyed by everyone, while alleviating feelings of isolation, loneliness and boredom. Staff stated there has been a positive change in resident moods and social interaction since the start of the sessions in May 2015. Residents interviewed expressed enthusiasm for the therapy, although most did not identify it as therapy. A concert was planned for the mid-winter Christmas dinner and residents rehearsed for the event. Photographs identified residents participating during the concert. Criterion 3.5.7 Results of surveillance, conclusions, and specific recommendations to assist in CI All infections at Walmsley House are logged and benchmarked with an external organisation. The benchmarking data is discussed at PSS Walmsley House benchmarks around infections in four areas - wound Infections - with and without pathology, skin infections - with and without pathology, infections (total) - with and without pathology and infections (UTI) - with and without pathology. In