The infection control surveillance programme is appropriate to the size and complexity of the service. Results of surveillance are acted upon, evaluated and reported to relevant personnel. 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 15 0 3 1 0 0 Criteria 0 38 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
Specific results for criterion where corrective actions are required 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 Audit Finding Corrective action required and timeframe for completion (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 Moderate The standing orders policies and procedures in place meet legislative requirements, but the standing orders form had not been signed by the GP. Medications were stored safely in line with legislation, however, weekly CD register checks were not consistently carried out. i) The standing orders form that was in use had not been signed by the GP ii) CD register weekly medication checks were not evidenced on eight occasions in the past 12 weeks. i) Ensure that standing orders are signed by the GP ii) Ensure that CD register medication checks are completed according to organisational and legislative requirements. 30 days Criterion 1.3.13.5 All aspects of food procurement, production, preparation, storage, transportation, delivery, and PA Low Food temperatures were monitored and recorded before food was transported to Sunningdale. All staff involved in food preparation have received food safety training. All food stored in the fridge was Dry goods are not stored appropriately in the kitchen pantry. Ensure that all dry goods and pantry items are stored appropriately.
disposal comply with current legislation, and guidelines. covered and dated. Dry goods and pantry items were not stored correctly. 60 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 The registered nurse completes initial assessments and an initial care plan on admission. The long-term care plan is completed within 21 days using the interRAI assessment tool and other relevant clinical assessment tools. Four of five files reviewed had an interRAI assessment completed within the required timeframes. Four of five files sampled had the long-term care plan completed within the required timeframe. i) One of five (rest home) admitted in July 2015 did not have an interRAI assessment completed within 21 days of admission; and ii) One of five (rest home) did not have the long-term care plan completed within 21 days of admission. i) Ensure that all interRAI assessments are completed within the required timeframes. ii) Ensure that all care plans are documented within 21 days of admission. 90 days Criterion 1.3.6.1 The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes. PA Low Assessments are completed on admission, when the care plan is reviewed and with a change in health condition. The RN reviews information gathered using assessments and monitoring charts to ensure interventions are documented in the care plans to reflect current care needs. Four of five files reviewed evidenced that interventions were documented for all identified care needs. The care plan for one hospital resident with unstable diabetes did not document the monitoring and interventions required for the management of hyperglycaemia and hypoglycaemia. Ensure that interventions are documented for all assessed care needs 60 days