Team Lead Auditor XXXXXX Hours on site 12.5 off site 8 Other Auditors XXXXXX Total hours on site 12.5 Total hours off site 8 Technical Experts hours on site Total hours off site Consumer Auditors hours on site Total hours off site Peer Reviewer XXXXXX Hours 2 Sample Totals Total audit hours on site 25 Total audit hours off site 18 Total audit hours 43 Number of residents interviewed 5 Number of staff interviewed 8 Number of managers interviewed 2 Number of residents’ records reviewed 5 Number of staff records reviewed 6 Total number of managers (headcount) 2 Number of medication records reviewed 10 Total number of staff (headcount) 68 Number of relatives interviewed 8 Number of residents’ records reviewed using tracer methodology 3 Number of GPs interviewed 1
in full in the policy and occurs according to policy. Data is reported to head office and benchmarked between Bupa facilities. Data is reported by the clinical manager to facility staff at the monthly quality meeting held within the facility so that all staff are aware of IPC. The IPC programme is linked with the quality management programme. An outbreak of norovirus occurred early in 2014 in the dementia unit and was identified, contained within the dementia unit and fully resolved within six days. Summary of Attainment CI FA PA Negligible PA Low PA Moderate PA High PA Critical Standards 0 13 0 3 0 0 0 Criteria 0 35 0 4 0 0 0 UA Negligible UA Low UA Moderate UA High UA Critical Not Applicable Pending Not Audited Standards 0 0 0 0 0 0 0 34 Criteria 0 0 0 0 0 0 0 62 Corrective Action Requests (CAR) Report Code Name Description Attainment Finding Corrective Action Timeframe (Days) HDS(C)S.2008 Standard 1.2.7: Human Resource Management Human resource management processes are conducted in accordance with good employment practice and meet the requirements of legislation. PA Low HDS(C)S.2008 Criterion 1.2.7.5 A system to identify, plan, facilitate, and record ongoing education for service providers to provide safe and effective services to consumers. PA Low One of the five caregivers who are working on dementia standards has been employed for over one year. She has completed two of her four dementia standards. The care home manager reports that she anticipates that this caregiver will complete her remaining two dementia standards in approximately two months’ time. Ensure all caregivers who work in the dementia unit are enrolled to complete dementia standards in the first six months of employment and have completed their dementia standards within one year of employment. 180
HDS(C)S.2008 Standard 1.3.3: Service Provision Requirements Consumers receive timely, competent, and appropriate services in order to meet their assessed needs and desired outcome/goals. PA Low HDS(C)S.2008 Criterion 1.3.3.3 Each stage 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 GP is not recording whether a resident’s medical condition is stable when reviewing residents monthly (refer ARC D16.5, e.I, 1). Care staff are not monitoring the urinary output of the resident with the xxxxx according to the plan of care. Ensure the GP records in the resident’s medical records that the resident’s medical condition is stable if they intend to next review their health three monthly rather than monthly. Ensure clinical practice matches the requirements of the plan of care for the resident with the xxxxxxxxx 60 HDS(C)S.2008 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. PA Low HDS(C)S.2008 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 to comply with legislation, protocols, and guidelines. PA Low A rest home resident is being supplied with controlled drugs on a regular basis from the hospital residents’ imprest stock of controlled drugs. Ensure the bulk supply of controlled drug medicines occur according to the Medicine Care Guides published by the Ministry of Health. 30 HDS(C)S.2008 Criterion 1.3.12.5 The facilitation of safe of medicines by consumers where appropriate. PA Low One resident is self-administering medicines. This information was not noted on her medicine order and she was not storing them in a locked area when not in use. Ensure the practice of of medicines occurs according to the Medicine Care Guides published by the Ministry of Health. 30 Continuous Improvement (CI) Report Code Name Description Attainment Finding
The kitchen stores at least three days of food to ensure residents and staff can be fed if supplies are disrupted due to a civil defence emergency. The kitchen was the subject of a complaint to the Council recently by disgruntled staff member. The Council inspected the premises and stated they were happy with the overall standard of the kitchen. They recommended that management repair a join in the flooring when conducting routine maintenance. The Council did not view the repair as being urgent and in the meantime temporary repairs have been implemented. Criterion 1.3.13.1 (HDS(C)S.2008:1.3.13.1) Food, and nutritional needs of consumers are provided in line with recognised nutritional guidelines appropriate to the consumer group. Attainment and Risk: FA Evidence: Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.) Criterion 1.3.13.2 (HDS(C)S.2008:1.3.13.2) Consumers who have additional or modified nutritional requirements or special diets have these needs met. Attainment and Risk: FA Evidence: Finding: Corrective Action: Timeframe (days): (e.g. for 1 week choose 7, for 1 month choose 30, for 6 months choose 180, etc.)