zilongwang/ReadingBank huggingface dataset:
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 areas. 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
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 0 0 0 0 Criteria 0 93 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
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 12 0 2 3 0 0 Criteria 0 35 0 2 3 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
indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome. files which are signed by the RN. One resident has been in the service less than six months. dementia unit and one at hospital level; ii) the ongoing monitoring of resident need is not documented one resident in the hospital unit bed rails for restraint; iii) RN review and/ or monitoring of identified issues is not documented for one resident following a fall and a painful leg, one resident following an ‘as needed’ medication in the dementia unit, and one resident at hospital level with a swollen knee. identified resident issues and plans of care. 60 days
contribute to, meeting the consumers' assessed needs, and desired outcomes. area that identify which residents have wounds and a management dressing regime. Fifteen of nineteen wounds did not have the timeframe for the next review/dressing documented. This has been identified as low risk due to the wounds being managed appropriately, reviewed and evaluated at each dressing change. documented. Ensure that there is documented timeframes for reviews and dressings. 60 days Criterion 2.2.3.2 Approved restraint is only applied as a last resort, with the least amount of force, after alternative interventions have been considered or attempted and determined inadequate. The decision to approve restraint for a consumer should be made: (a) Only as a last resort to maintain the safety of consumers, service providers or others; (b) Following appropriate planning and preparation; (c) By the most appropriate health professional; (d) When the environment is appropriate and safe for successful initiation; (e) When adequate resources are assembled to ensure safe initiation. PA Low The two restraint sampled included monitoring requirements (both two hourly) on the monitoring form and in the care plan. Monitoring forms were in place for both residents, but two hourly monitoring is not always documented. The two restraint monitoring forms sampled did not consistently document the required two hourly monitoring. Ensure restraint monitoring occurs within the designated timeframes and that this is documented. 90 days
MidCentral District Health Board Introduction This report records the results of a Surveillance Audit of a provider of hospital services against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008). The audit has been conducted by The DAA Group Limited, an auditing agency designated under section 32 of the Health and Disability Services (Safety) Act 2001, for submission to the Ministry of Health. The abbreviations used in this report are the same as those specified in section 10 of the Health and Disability Services (General) Standards (NZS8134.0:2008). You can view a full copy of the standards on the Ministry of Health’s website by clicking . The specifics of this audit included: Legal entity: MidCentral District Health Board Premises audited: Horowhenua Health Centre||Palmerston North Hospital Services audited: Hospital services - Psychogeriatric services; Hospital services - Medical services; Hospital services - Mental health services; Hospital services - Geriatric services (excl. psychogeriatric); Hospital services - Children's health services; Hospital services - Surgical services; Hospital services - Maternity services Dates of audit: Start date: 17 November 2015 End date: 19 November 2015 Proposed changes to current services (if any): None Total beds occupied across all premises included in the audit on the first day of the audit: 356
Criterion 1.2.7.3 The appointment of appropriate service providers to safely meet the needs of consumers. PA Low The organisational policy requires that all new staff have police vet checks completed as part of the recruitment process, however, this was not always evidenced. Two new staff recently recruited had not had the mandatory police vet checks completed. Ensure that the organisational requirement for all new staff to have police vet checks is followed. 60 days Criterion 1.2.7.4 New service providers receive an orientation/induction programme that covers the essential components of the service provided. PA Low The organisation has a comprehensive orientation/induction programme for all new staff; however, in the staff files reviewed not all staff have completed the organisational orientation requirements. All staff are required to have signed job descriptions which outline the requirements of their role. Not all staff had signed job descriptions on file. i) Two of two new had no evidence that they had completed the organisations orientation requirements. ii) Three of seven staff files sampled do not have signed job descriptions on file. i) Ensure that all new staff complete the orientation/induction process. ii) Ensure that all staff have a signed job description. 60 days Criterion 1.2.7.5 A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers. PA The service has an annual education planner that has scheduled education to cover the requirements of the Age Related Resident Contract. Not all topics outlined on the schedule have been delivered. Where training has occurred staff attendance has been low. i) Education has not been provided in the past 12 months for chemical safety training, abuse and neglect prevention, wound management and pressure injury prevention, infection control, and challenging behaviour, and restraint minimisation. ii) Education has not been provided in the past 2 years for advocacy, resident i) Ensure that the education schedule is fully implemented and education is provided to cover all contractual and legal requirements. ii) Ensure that a process is put in place to ensure that all staff attend mandatory education and where attendance is low an education follow-up plan is implemented.
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 Rating Audit Evidence Finding Corrective action required and timeframe for completion (days) Criterion 1.2.3.6 Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers. PA Low Quality improvement activities include completion of the internal schedule, feedback from residents, families and staff via complaints and surveys, complaints process and incidents and accidents. Incident reports are completed by care staff and registered nurses and are then reviewed by the nurse manager. The incident data is then entered on to a Summerset data base (SWAY). On review of the previous three months, it was noted that not all incident report forms have been entered on to the data base. Data relating to 17 incident reporting forms for December 2015 has not been collected or entered on to the SWAY data base. Ensure that all incident reports are collated and analysed to identify opportunities for improvement. 90 days Criterion 1.3.3.3 PA Moderate Care plan documentation is still in progress. InterRAI assessments were not completed as required for i) Two out of five files reviewed did not have interRAI assessments completed within 21 days of admission. Interview with the clinical nurse lead, the nurse i)Ensure that interRAI assessments are completed within 21 days of admission;
Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.) Criterion 1.1.13.3 (HDS(C)S.2008:1.1.13.3) An up-to-date complaints register is maintained that includes all complaints, dates, and actions taken. 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.) Outcome 1.2: Organisational Management Consumers receive services that comply with legislation and are managed in a safe, efficient, and effective manner. Standard 1.2.1: Governance (HDS(C)S.2008:1.2.1) The governing body of the organisation ensures services are planned, coordinated, and appropriate to the needs of consumers. ARC A2.1; A18.1; A27.1; A30.1; D5.1; D5.2; D5.3; D17.3d; D17.4b; D17.5; E1.1; E2.1 ARHSS A2.1; A18.1; A27.1; A30.1; D5.1; D5.2; D5.3; D17.5 Attainment and Risk: FA Evidence: Malvina Major provides care across two levels. The ground floor has 60 rest home beds, of which 20 have been assessed as suitable for dual purpose – i.e. rest home and/or hospital level. Level one has 60 hospital level beds. In addition 20 of the serviced apartments have been certified suitable for rest home level residents. On the day of audit there are 45 rest home and 12 hospital level residents (of 60) on the ground floor, 58 (of 60) hospital residents, and four rest home residents in the serviced apartments. This gives a total of 49 rest home residents (including one respite), and 70 hospital level residents.
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 37 0 5 3 0 0 Criteria 0 84 0 6 3 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
Wound assessment, monitoring and wound management plans are in place in all files sampled. The RN has access to specialist nursing wound care management advice through the district nursing service. Interviews with clinical manager and the caregivers demonstrated an understanding of the individualised of residents. Care plan interventions demonstrate interventions to meet residents’ needs. Adequate dressing supplies were sighted in treatment There is evidence of GP, dietician and specialist involvement in wounds/pressure areas. On the day of audit there were six skin tears and no pressure injuries. All wound care documentation was fully completed. Standard 1.3.7: Planned Activities Where specified as part of the service delivery plan for a consumer, activity requirements are appropriate to their needs, age, culture, and the setting of the service. FA The service has a registered diversional therapist (DT) who oversees the recreational officer and two activities assistants. An activity profile and Map of Life is completed on admission in consultation with the resident/family (as appropriate). Activity plans sighted in all seven files cover the 24-hour period and were reviewed six monthly at the same time as the care plans. There is a wide range of activities offered that reflect the resident’s needs and participation is voluntary. One-on-one activities occur for residents who are unable or choose not to be involved in activities. Activity participation sheets were maintained in files sampled. The service receives feedback and suggestions for the programme through surveys and one on one feedback from residents (as appropriate) and families. Care staff were observed at various times through the day diverting residents from behaviours. The individual activities observed were appropriate for older people with dementia. There are resources available for care staff to use for one on one time with the resident over the 24-hour period. Relatives stated they were satisfied with the activities provided and that staff were involved in activities with their loved ones, even if only passive participation. Standard 1.3.8: Evaluation Consumers' service delivery plans are evaluated in a comprehensive and timely manner. FA Care plans reviewed at least six monthly and have been updated as changes were noted in care requirements. Care plan evaluations reviewed were comprehensive, relate to each aspect of the care plan and record the degree of achievement of goals and interventions. Short-term care plans are utilised for
reconciliation in order to comply with legislation, protocols, and guidelines. Administration Policy (last review 2013). The policy covers for all prescribing practices including all legal requirements when prescribing and administering medicines. The LMC is responsible for prescribing medicines that are required for normal delivery and post-natal care. Five infant’s medication charts were reviewed and five maternal charts. a prescription/medication chart for medication identified as given; (iv) one of ten files did not have the date, route or indication for medication given. medications for mother or baby while inpatients in the facility. 60 days Criterion 1.3.13.5 All aspects of food procurement, production, preparation, storage, transportation, delivery, and disposal comply with current legislation, and guidelines. PA Low All chilled and frozen goods are stored at correct temperatures as evidenced on the temperature recording sheets. Serving temperatures on all meals have been recorded however end cooked temperatures have not been taken and recorded. is a food handling policy and food storage policy documented as part of the IC guidelines/policies. Any other food the clients request is brought in for mothers by family members/visitors. End cooked temperatures have not been taken or recorded for meats/poultry as per protocol. Ensure end cooked temperatures for meat/poultry are taken and recorded as per protocol. 90 days 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 Low All resident files reviewed had initial assessments and risk assessments completed on admission. The care plan had been developed within twenty-one days of admission in four of the five files reviewed. The interRAI assessment had been completed in the file of one new admission under the ARCC contract. One hospital resident admitted for permanent care under another contract (ACC) did not have a long-term care plan completed within twenty-one days of admission. Ensure long-term care plans are developed within 21 days of admission for all new admissions. 90 days
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
meetings and discussed. Registered nurse meetings have recommenced April 2016. 60 days 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 Care plans are overall comprehensive but two care plans were noted to have interventions that were contradictory and one did not contain sufficient information to guide staff (i)One rest home care plan stated resident is on a soft diet with low roughage but further on states resident is on a normal diet and to give high fibre. (ii) One rest home resident regularly has alcohol and is an increased falls risk but this is not documented clearly in the care plan; (iii) one hospital resident’s (YPD) care plan states resident is continent of urine and faeces and uses tena pads but further on states resident has an indwelling catheter. Ensure all interventions are clear and fully documented 60 days
Safe and appropriate environment 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. A current building warrant of fitness is displayed. Residents’ rooms are of sufficient space to allow services to be provided and for the safe use and manoeuvring of mobility aids. Residents can and do bring in their own furnishings for their rooms. There are lounge and dining areas in the facility. There are also small seating areas throughout the facility. Furniture is appropriate to the setting and arranged that allows residents to mobilise. There is a designated laundry with secure storage of cleaning and laundry chemicals. Chemicals are stored in a locked storage cupboard. The service has implemented policies and procedures for civil defence and other emergencies. Alternative power and cooking facilities are available in the event of a power failure. Communal living areas and resident rooms are appropriately heated and ventilated. Residents have access to natural light in their rooms and there is adequate external light in communal areas. External garden areas are available with suitable pathways, seating and shade provided. 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. Mayfair is aiming and working towards a restraint-free environment. Policy and procedures are in place. There is a designated restraint coordinator. Staff receives training in restraint minimisation and challenging behaviour management. On the day of audit, the service had four residents using restraint in the form of bedrails and no residents with an enabler.
assessed needs, and desired outcomes. clinical care provided. Not all documentation is completed as required. management of three different wounds. (iv) wound dressings are completed by the senior caregivers (RN assistants). Wound care reviews were only referred to an RN if the registered nurse assistant considered that the dressing needed review. are involved in the assessment and management of wounds. 30 days
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. No data to display
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 48 0 2 0 0 0 Criteria 1 98 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
(b) Details of alternative interventions (including techniques where applicable) that were attempted or considered prior to the use of restraint; (c) Details of any advocacy/support offered, provided or facilitated; (d) The outcome of the restraint; (e) Any injury to any person as a result of the use of restraint; (f) Observations and monitoring of the consumer during the restraint; (g) Comments resulting from the evaluation of the restraint. consistent. That is, staff are clustering monitoring times and signing off once per shift. and signing off once per shift.
The infection control programme and its content and detail are appropriate for the size, complexity and degree of risk associated with the service. The infection control coordinator (registered nurse) is responsible for collating infection events and providing a monthly report to management and staff. Infection control policies and guidelines include definitions for surveillance. The infection control coordinator uses the information obtained through surveillance to determine infection control activities and education needs within the facility. 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 0 16 0 2 1 0 0 Criteria 0 39 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
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 1 1 0 0 Criteria 3 88 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
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. There is evidence that residents and family are kept informed. The rights of the resident and/or their family to make a complaint is understood, respected and upheld by the service. All lodged complaints are documented in the complaints register and managed appropriately. Organisational management Includes 9 standards that support an outcome where 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. Services are planned, coordinated and are appropriate to the needs of the residents. A care home manager and clinical manager are responsible for the day-to-day operations of the facility. Goals are documented for the service with evidence of annual reviews. Corrective actions have been implemented where opportunities for improvements are identified. A risk management programme is in place, which includes managing adverse events and health and safety processes. Residents receive appropriate services from suitably qualified staff. Human resources are managed in accordance with good employment practice. A comprehensive orientation programme is in place for new staff. Ongoing education and training is in place for staff. Registered nursing cover is provided 24 hours a day, 7 days a week.
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 ongoing 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. 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 39 0 5 0 0 0 Criteria 1 87 0 5 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)
included skin care and repositioning of the resident. Criterion 1.4.2.1 All buildings, plant, and equipment comply with legislation. PA Low Maintenance is undertaken by both internal maintenance personnel and external contractors. Electrical safety test tag system shows this has occurred. The facility is being maintained in good repair. All maintenance records were reviewed and are clearly documented. The maintenance records were reactive maintenance. There was no documented preventative maintenance schedule. Water temperatures are monitored. It was identified that whenever it was out of range, corrective actions had not been completed. There was no documented preventative maintenance schedule. Water temperatures are monitored. It was identified that whenever it was out of range, corrective actions had not been completed. Document and implement an annual preventative maintenance schedule; (ii) Ensure corrective actions are documented when water temperatures are above 45 degrees. 90 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 0 17 0 0 0 0 0 Criteria 0 40 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
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 prevention and control is well managed. have access to a range of personal protective equipment and receive ongoing training related to infection control. Well-established processes are in place to ensure infection surveillance is systematic. Appropriate action is taken as required in relation to surveillance results, including effectively communicating these results with staff. 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 1 2 0 0 Criteria 1 97 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)
nurse who has completed infection control education. Staff receives regular infection control training. Policies and procedures reflect best practice including definitions for surveillance. Monthly infection events are collated and forwarded to head office for analysis and organisational benchmarking. The results of surveillance are used to identify infection control quality initiatives and education requirements. There was one outbreak in 2015 which was well managed by the service. 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 5 44 0 1 0 0 0 Criteria 6 94 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
Criteria 6 94 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
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 Audit Evidence Audit Finding Criterion 1.2.3.1 The organisation has a quality and risk management system which is understood and implemented by service providers. CI Royal Heights is continuing to achieve the quality goals which are set annually. The service is ready to engage in using the interRAI data warehouse for comparison and analysis of their data. Although the service has not had residents with pressure injuries, a new audit tool for pressure injury prevention has been added to the schedule and incident and accident documents have been updated to include reporting on these. Where audits reveal areas that do not attain 100% of the outcomes, there was documented evidence of investigations and remedial actions being taken immediately. All corrective actions are documented on audit action sheets and signed off when tasks are completed. A medicines audit in 2015 revealed 18 omissions by the prescriber to sign off discontinued medicines. The service introduced an electronic prescribing and medicines management system in November 2015 and a re-audit two months later revealed no omissions or errors. Review of residents’ meeting Having fully attained this criterion the service demonstrates that it continues to review and evaluate its quality and risk management systems and take actions which improve and strengthen its methods for performance monitoring. This has lead to safer systems, improved outcomes for residents and greater participation by consumers.
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 Rating Audit Evidence Audit Finding Corrective action required and timeframe for completion (days) Criterion 1.2.3.6 Quality improvement data are collected, analysed, and evaluated and the results communicated to service providers and, where appropriate, consumers. PA Low Quality data is collected and collated. The staff member responsible reported graphs are generated. However, these are basic and staff reported they have not seen them. Staff reported they discuss the clinical indicators during the staff meetings to identify any trends. There was no documented evidence to support this. There was documented numbers of clinical indicators for the month, but no evidence of any analysis to identify trends. Although staff reported they discuss analysis and trends during their staff meetings, there was no documented evidence that clinical indicators are analysed to identify any trends. Meeting minutes evidenced numbers only are reported back to staff, apart from falls with injury or without injury. Provide documented evidence that quality data is analysed to identify trends and that this is reported back to staff. 180 days Criterion 1.2.3.8 A corrective action plan addressing areas requiring improvement in order to meet the PA Low Corrective action plans were evidenced in the quality and staff meeting minutes. Some internal audits had corrective action plans, but these were inconsistent and documented what the problem was, Corrective action plans are not always developed following deficits identified. Where corrective action Develop and implement corrective action plans for all deficits identified
Audit Team Lead Auditor XXXXXXXX Hours on site 4 Hours off site 2 Auditors Total hours on site Total hours off site Technical Experts Total hours on site Total hours off site Consumer Auditors Total hours on site hours off site Peer Reviewer XXXXXXX Hours 2 Sample Totals audit hours on site 4 Total audit hours off site 4 audit hours 8 Number of residents interviewed Number of interviewed 2 Number of managers interviewed 1 Number of residents’ records reviewed 8 Number of staff records reviewed 5 Total number of managers (headcount) 1 Number of medication records reviewed 14 Total number of staff (headcount) 97 Number of relatives interviewed Number of residents’ records reviewed using tracer methodology Number of GPs interviewed
The treatment room in the new wing is not yet secure. HDS(C)S.2008 Standard 1.4.2: Facility Specifications Consumers are provided with an appropriate, accessible physical environment and facilities that are fit for purpose. PA Low HDS(C)S.2008 Criterion 1.4.2.1 All buildings, plant, and equipment comply with legislation. PA Low A code of compliance has not yet been obtained for the new wing. Ensure a code of compliance is obtained and provided to the DHB. Prior to occupancy HDS(C)S.2008 Standard 1.4.7: Essential, Emergency, And Security Systems Consumers receive an appropriate and timely response during emergency and security situations. PA Low HDS(C)S.2008 Criterion 1.4.7.3 Where required by legislation there is an approved evacuation plan. PA Low The fire evacuation plan has yet to be signed off as approved by the fire service. Ensure the updated evacuation scheme is signed off by the Fire service. 30 HDS(C)S.2008 Criterion 1.4.7.5 An appropriate 'call system' is available to summon assistance when required. PA Low The call bell system is yet to be connected. Ensure the call bell system is operational. to occupancy Continuous Improvement (CI) Report Code Name Description Attainment Finding NZS 8134.1:2008: Health and Disability Services (Core) Standards
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 41 0 4 0 0 0 Criteria 0 89 0 4 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
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
comply with current legislation, and guidelines. temperatures of these appliances were not monitored. for all fridges and freezers. 90 days Criterion 1.3.3.3 Each of service provision (assessment, planning, provision, evaluation, review, and exit) is provided within time frames that safely meet the needs of the consumer. PA Low In the six files reviewed an initial care plan and assessment had been completed. The registered nurse/interim manager reported these are always completed on the day of admission. However, the newly developed initial assessment and care plan form does not require a date or signature, so this could not be confirmed. Four of six resident files sampled did not have a date or signature on the initial assessment and care plan (the newly developed initial assessment and care plan form does not require a date or signature, so completion date could not be confirmed). Ensure that initial assessments and care are completed within required timeframes and signed and dated to demonstrate this. 90 days Criterion 1.3.3.4 The service is coordinated in a manner that promotes continuity in service delivery and promotes a team approach where appropriate. PA Low Progress notes, GP notes and notes from visiting allied health professionals are documented in the electronic database. Most entries are made by the previous manager (who left one week prior to the audit) or the registered nurses with a minority of entries from the caregivers. Not all files demonstrated consistent entry of progress notes. Four of six files sampled had intervals of between nine days and fourteen days over the previous two months where no progress notes had been recorded. Ensure progress notes are recorded regularly to demonstrate a record of the resident’s ongoing progress. 90 days Criterion 1.4.2.1 All buildings, plant, and equipment comply with legislation. PA Low Scheduled maintenance occurs with sub-contractors providing fire testing, electrical and plumbing work. Staff inform the maintenance person of any issues that require attention. Monthly hot water checks are conducted in the laundry, kitchen and in a sample of resident rooms. The hot water records for the past five months were reviewed and evidence that January to March temperatures are within the Hot water temperature records for April and May evidence that resident hot water has been delivered consistently above 45 degrees Celsius (46-50). Corrective actions have not Provide evidence that hot water is provided to residents at appropriate temperature levels.
Team Lead Auditor XXXXXXXX Hours on site 24 Hours off site 12 Other Auditors XXXXXXXX Total hours on site 24 Total hours off site 8 Technical Experts Total hours on site Total hours off site Consumer Auditors Total hours on site Total hours off site Peer Reviewer XXXXXXXX Hours 3 Sample Totals Total audit hours on site 48 Total audit hours off site 23 audit hours 71 Number of residents interviewed 10 Number of staff interviewed 18 Number of managers interviewed 7 Number of residents’ records reviewed 14 Number of staff records reviewed 13 Total number of managers (headcount) 7 Number of medication records reviewed 30 Total number of staff (headcount) 75 Number of relatives interviewed 11 Number of residents’ records reviewed using tracer methodology 3 Number of GPs interviewed 2
Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.) Criterion 2.2.3.4 (HDS(RMSP)S.2008:2.2.3.4) Each episode of restraint is documented in sufficient detail to provide an accurate account of the indication for use, intervention, duration, its outcome, and shall include but is not limited to: (a) Details of the reasons for initiating the restraint, including the desired outcome; (b) Details of alternative interventions (including de-escalation techniques where applicable) that were attempted or considered prior to the use of restraint; (c) Details of any advocacy/support offered, provided or facilitated; (d) The outcome of the restraint; (e) Any injury to any person as a result of the use of restraint; (f) Observations and monitoring of the consumer during the restraint; (g) Comments resulting from the evaluation of the restraint. 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 2.2.3.5 (HDS(RMSP)S.2008:2.2.3.5) A restraint register or equivalent process is established to record sufficient information to provide an auditable record of restraint use. Attainment and Risk: FA Evidence: Finding: Corrective Action:
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 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 1.2.7.5 A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers. CI The service has an annual training schedule with very good attendance at training sessions by staff. There are compulsory study days planned biannually for all caregivers that provide all compulsory education for staff, there are also study days for trained staff. Policies and procedures are based on evidenced and best practice and communicated to all staff. The service evaluated the quality and training process during 2013. The review identified the current system did not identify service risks, there was a lack of staff involvement in the quality process and this affected the training attendance levels. Because of this, a new of audit tools were developed and implemented onto practice in late 2013. This was accompanied by a new training schedule (based on a review of training provided at the time and staff feedback). The reviewed audits were to ensure that critical areas of risk were identified. Other actions included a simplified meeting minute format, and adjustments were made to the process of education session delivery to make it more accessible to staff. The reviewed