The facility is managed by an experienced and suitably qualified manager who has a background in quality. The facility manager is non-clinical and is supported by a clinical manager/registered nurse. The facility manager and clinical manager are supported by a clinical co-ordinator/registered nurse. The clinical manager is responsible for the oversight of the clinical services in the facility. Quality and risk management systems are in place. There is an internal audit programme, risks are identified and there is a hazard register. Adverse events are documented on accident/incident forms. Internal audits, accident/incident forms, and meeting minutes evidenced corrective action plans were being developed, implemented, monitored and signed off as being completed to address the issue/s that required improvement. Various meetings are held and there was reporting on numbers of various clinical indicators, quality and risk issues and discussion of any trends identified in these meetings. Graphs of clinical indicators were available for staff to view along with meeting minutes. There are policies and procedures on human resource management, which are implemented at the service. An in-service education programme is provided for staff and study days are held several times during the year. Staff are also required to complete the New Zealand Qualifications Authority Unit Standards. There is a documented rationale for determining staffing levels and skill mixes in order to provide safe service delivery that is based on best practice. The clinical manager and clinical co-ordinator are rostered on call after hours. Resident information is entered into a register in an accurate and timely manner. The privacy of resident information is maintained. The name and designation of staff making entries into residents’ clinical records was legible. Continuum of service delivery 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. Standards applicable to this service fully attained. Services are being provided by a range of health professionals. Entry to services is made in a timely and equitable manner. Assessments, service plans and evaluations are completed in a comprehensive manner. Clinical and medical needs are identified
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. There are adequately documented guidelines on the use of restraints and enablers and behaviours of concern. Restraint use is minimised if able and the use of enablers is voluntary. In the event of restraint use, the required approval, consent, assessment, monitoring and review is conducted. The safety and use of restraint is reviewed regularly to ensure ongoing appropriateness. 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 evidenced that relevant infection control education is provided to all service providers as part of their orientation and also 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 of infections are acted upon, evaluated and reported to relevant personnel in a timely manner.
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 50 0 0 0 0 0 Criteria 0 101 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