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. The infection prevention and control policies and procedures include guidelines on prevention and minimisation of infection and cross infection, and meet the requirements of the standard. The policies and procedures guide staff in all areas of infection control practice. New employees are provided with training in infection control practices and there is an on-going infection control education available for all staff. Infection control is a standard agenda item at facility’s meetings. Staff interviews confirmed staff are familiar with infection control measures at the facility. The information sampled confirms that the surveillance programme is appropriate for the size and complexity of the services provided. 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 applicable to this service 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 1 3 0 0 Criteria 0 89 0 1 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
the basis for service delivery planning. were aware of the individual resident’s triggers or the management of the individual challenging behaviours of residents. All of the six files reviewed of the residents’ with challenging behaviour did not evidence challenging behaviour assessments. In the resident’s file of a resident who was assessed by the GP as requiring PRN pain relief did not evidence the effectiveness of the treatment (the PRN pain medication) on the pain monitoring tool or in the progress notes or reassessment of pain assessment completed medication chart evidenced the PRN pain relief was changed to regular pain relief to manage the pain. 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 Moderate All six reviewed of the residents’ with challenging behaviour did not evidence challenging behaviour assessments (criterion 1.3.4.2). The care plan interventions do not consistently reflect individualised care requirements relating to behaviours that challenge (six of six files). The long term care plans do not consistently describes the required interventions around behaviours that challenge. Provide evidence the long term care plans describe the required support and interventions relating to behaviours that challenge. 60 days Criterion 1.3.8.2 Evaluations are documented, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome. PA Moderate I) Two of eight care plan evaluations did not evaluate all identified patients’ needs; such as challenging behaviour and medical condition. Two of eight care plan evaluations (different files) did not record evidence of the degree of achievement towards meeting the residents’ needs. Additional six hospital files were reviewed in relation to care plan evaluation. Two of the six additional hospital files did not record the evidence of the degree of achievement towards meeting the resident’s needs. i) Care plan evaluations are not consistently recorded for all identified needs and do not always indicate the degree of achievement towards meeting residents’ goals. ii) Evaluations of wounds are not always completed according to the wound care plan evaluation timeframes. Provide evidence that evaluations are documented for all resident’s care needs and record the degree of achievement towards meeting these needs. 60 days