Infection control management systems are in place to minimise the risk of infection to consumers, service providers and visitors. Documented policies and procedures are in place for the prevention and control of infection and reflect current accepted good practice and legislative requirements. 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. 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) 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 46 0 2 0 0 0 Criteria 4 95 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
from residential care to the DHB acute hospital. Relatives are notified if transfers occur. Standard 1.3.12: Medicine Management Consumers receive medicines in a safe and timely manner that complies with current legislative requirements and safe practice guidelines. FA Twenty-six medication files were sampled (six rest home, ten hospital, and ten dementia level of care). The service uses an electronic medication management system. The medication management policies comply with medication legislation and guidelines. All required medication checks had been completed. Medicines are appropriately stored in accordance with relevant guidelines and legislation. Resident’s medicines are stored securely in the medication rooms. Medication administration practice complies with the medication management policy for the medication round sighted. Registered nurses and caregivers administer medicines. All staff that administer medicines are competent and have received medication management training. The facility uses a robotically packed medication management system for the packaging of all tablets. Two RNs reconcile the delivery of new medication and document this. There was evidence of three monthly reviews by the GP. All residents self-administering their own medication had completed the required competency assessments. Standing orders are not used. Standard 1.3.13: Nutrition, Safe Food, And Management A consumer's individual food, fluids and nutritional needs are met where this service is a component of service delivery. FA There is a food services policy and procedure manual. All food is cooked onsite. A dietitian has reviewed and approved the menu. All residents have a dietary requirements/food and fluid chart completed on admission. The cook maintains a folder of residents’ dietary requirements that include likes/dislikes. Alternatives are offered and alternatives are provided as needed. Specialised utensils and lip plates are available as required. Residents and relatives interviewed confirm likes/dislikes are accommodated and alternatives offered. Fridge and freezer temperatures are recorded daily for the kitchen appliances. Perishable foods in the chiller and refrigerators are date-labelled and stored correctly. The kitchen is clean and has a good workflow. Chemicals are stored safely and safety datasheets are available. Personal protective equipment is readily available and staff were observed to be wearing hats, aprons and gloves. The service has implemented an empowering process associated with meals for residents across all areas (link CI 1.1.8.1).
There is a managed environment, which minimises the risk of infection to consumers, service providers, and visitors. This shall be appropriate to the size and scope of the service. into the incident reporting system and the quality management system. One registered nurse is the designated infection control nurse with support from the clinical team, care managers and the quality manager. The IC team meets three monthly to review infection control matters. Regular audits have been conducted and education has been provided for staff and where required, residents (link 3.5). The infection control programme has been reviewed annually. Standard 3.2: Implementing the infection control programme There are adequate human, physical, and information resources to implement the infection control programme and meet the needs of the organisation. FA There are adequate resources to implement the infection control programme at Mary Doyle. The infection control (IC) coordinator has maintained her practice by attending infection control updates. The infection control team is representative of the facility. External resources and support are available when required. The IC coordinator is part of the DHB IC support group and journal club. Infection prevention and control is part of staff orientation and induction, and the planned education programme. Hand washing facilities are available throughout the facility and alcohol hand gel is freely available. Standard 3.3: Policies and procedures Documented policies and procedures for the prevention and control of infection reflect current accepted good practice and relevant legislative requirements and are readily available and are implemented in the organisation. policies and procedures are practical, safe, and appropriate/suitable for the type of service provided. FA The infection control manual outlines a comprehensive range of policies, standards and guidelines and includes roles, responsibilities, procedures, the infection control team and training and education of staff. The policies are reviewed and updated at least annually. Standard 3.4: Education The organisation provides relevant education on infection control to all service providers, support staff, and consumers. FA The facility is committed to the education of staff and residents (link 3.5). Education is facilitated by the staff educator with support from the infection control coordinator. All infection control training has been documented and a record of attendance has been maintained. Visitors are advised of any outbreaks of infection and are advised not to attend until the outbreak had been resolved. Posters regarding hand hygiene, and cough