Infection prevention and control education is included in the staff orientation programme, annual core training and in topical sessions. Residents are supported with infection control information as appropriate. Surveillance of infections is occurring according to the descriptions of the process in the programme. Data on the nature and frequency of identified infections has been collated and analysed. Surveillance results are benchmarked internally. The results of surveillance are reported through all levels of the organisation, including governance. 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 0 49 1 0 0 0 0 Criteria 3 97 1 0 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
Specific results for criterion where a continuous improvement has been recorded As well as standards, individual criterion within a standard can also be rated as having a continuous improvement. A continuous improvement means that the provider can demonstrate achievement beyond the level required for full attainment. The following table contains the criterion where the provider has been rated as having made corrective actions have been recorded. As above, criterion can be linked to the relevant standard by looking at the code. For example, a Criterion 1.1.1.1 relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights If, instead of a table, these is a message “no data to display” then no continuous improvements were recorded as part of this of this audit. Criterion with desired outcome Attainment Rating Audit Evidence Audit Finding Criterion 1.2.3.8 A corrective action plan addressing areas requiring improvement in order to meet the specified Standard or requirements is developed and implemented. CI Quality initiatives are developed in response to identified areas requiring improvement. These range from concerns raised by residents about the quality and enjoyment of meals, monitoring call bell response times and the palliative care suites to better support residents and their family/whanau at end of life. All initiatives have been documented and those which are completed have a formal review. The reviews and outcome of each initiative is discussed at the monthly management meeting when the quality plan is discussed as part of monitoring and tracking progress against the quality plan. Quality initiatives are identified and implemented. Once completed a formal review is conducted which includes consideration of improvement in service delivery as a result of the initiative. All initiatives are discussed and evaluated at the monthly management meetings. This initiative overall enables improvements in service delivery to be the ongoing focus of the staff and management team. Interview with a range of staff members identify that they are able to make improvements to anything which is identified as requiring improvement and they showed pride in the initiatives which have been implemented to date. The results of a range