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 2 12 0 2 0 0 0 Criteria 2 37 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
to admission and resident’s primary care is provided by the facility GPs unless the resident chooses another GP. Dressing supplies are available and a treatment room is stocked for use. Continence products are available and resident files include a urinary continence assessment, bowel management, and continence products identified for day use, night use, and other management. Specialist continence advice is available as needed. Wound assessment and wound management plans are in place for 11 residents with wounds. There is evidence in files of the wound specialist referrals. Wound care is completed within timeframes in 10 out of 11 wounds reviewed. One wound management plan included multiple wounds. 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. CI The recreational coordinator has worked at the service for six years. There are two additional activity officers who work in the facility across both service levels. All recreation/activities assessments and reviews were up to date in files sampled. On the day of audit, residents were observed being actively involved with a variety of activities in the main lounge and throughout the facility. Residents files sampled had a comprehensive assessment completed over the first few weeks after admission including a complete history of past and present interests, career and family. Activities are age appropriate and have been comprehensively planned. Activities provided are meaningful and reflect ordinary patterns of life. All residents and family members interviewed stated that activities are appropriate and varied and spoke positively about the programme. The service continues to exceed the standard around activities. Standard 1.3.8: Evaluation Consumers' service delivery plans are evaluated in a comprehensive and timely manner. FA Five of five initial care plans in files sampled were reviewed by an RN within three weeks of admission and care plans were evaluated at least six monthly or if there is a change in health status. There was a three monthly review by the GP in files sampled. Changes in health status were documented and followed up. GP's reviewed residents medication
one to one and is available on a weekly basis. Broadband and facilities are available for residents to use within the home. They use the IPads for Skype, crosswords, search engines, education and entertainment. The residents interviewed continue to use the IPads as a tool to socialise, keep entertained and maintain cognitive functions. One rest home resident interviewed (link tracer 1.3.3) reported the use of the IPad as having provided socialisation and stimulation and has improved well-being. Criterion 1.4.2.1 All buildings, plant, and equipment comply with legislation. CI The Lexham Park staff and manager survey residents including the facility environment and the environment is discussed at resident meetings. Ongoing improvements are made to meet resident and family suggestions and provide a more homelike environment. The environment at Lexham Park continues to offer appropriate indoor and outdoor areas appropriate for the residents and reminiscing their era. Lexham Park has continued to implement a number of new initiatives for improvements to the building including those in relation to resident and family feedback. Residents and family interviewed all commented positively around the environment and the services responsiveness around making improvements. Improvements since the previous audit have included (but are not limited to) providing abundant artwork to provide visual interest and stimulations that is by both nationally recognised and local artists and providing an aquarium in the east wing lounge and the west wing library to provide visual stimulation for more sedentary residents and development of a family area. This replicates a home kitchen living area and has a kitchenette (tea and coffee making facilities), a fridge, kitchen table and chairs and a small lounge area with a sofa and a television. This room has access to an outdoor table and chairs. The design of this space allows for intimate gatherings for family and residents to share as they would if they were in their own home environment. There is also a larger private space for family visits, which includes a dining space to share food. The residents and families interviewed stated that the facility, outdoor and indoor areas, the art and overall setting is appropriate to their age and era. End of the report.