comprehensive and timely manner. HDS(C)S.2008 Criterion 1.3.8.2 Evaluations are documented, consumer-focused, indicate the degree of achievement or response to the support and/or intervention, and progress towards meeting the desired outcome. PA Low There is no written six monthly evaluation in one hospital and one rest home file. Ensure written evaluations are completed six monthly. 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 Moderate 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 order to comply with legislation, protocols, and guidelines. PA Moderate 1) is no evidence of six monthly pharmacy audits of controlled drugs. 2) The standing order form does not comply with Ministry of Health standing order guidelines 2012. 3) There is transcribing on three out of 10 PRN medication administration forms. 4) The fentanyl patch is being signed when applied on the regular oral medication signing sheet. There are two signing sheets in place for one resident on XXXX. One form is for three times a day and the pharmacy generated signing sheet is for four times a day. 5) Two out of 10 medication charts did not have a GP signature for discontinued medications. 6) Nine out of 10 medications charts did not have an indication for use of PRN medications. 1) Ensure the pharmacy complete a pharmacy audit of controlled drugs six monthly. 2) Ensure the standing order form meets current guidelines 3) Transcribing is to cease. 4) Ensure correct administration signing sheets are used. 5) Ensure the GP signs for discontinued medications. 6) All PRN medications prescribed require an indication for use. 30 HDS(C)S.2008 Standard 1.4.6: Cleaning And Laundry Services Consumers are provided with safe and hygienic cleaning and laundry services appropriate to the setting in which the service is being provided. PA Moderate
HDS(C)S.2008 Criterion 1.4.6.3 Service providers have access to designated areas for the safe and hygienic storage of cleaning/laundry equipment and chemicals. PA Moderate There is no barrier between the kitchen and dining room to maintain resident safety from the staff only area. The chemical cupboard in the kitchen is not lockable. Ensure safe storage of chemicals within the kitchen. 30 HDS(C)S.2008 Standard 1.4.7: Essential, Emergency, And Security Systems Consumers receive an appropriate and timely response during emergency and security situations. PA Moderate HDS(C)S.2008 Criterion 1.4.7.5 An appropriate 'call system' is available to summon assistance when required. PA Moderate When activated a light appears at designated area/s throughout the facility. Response to resident calls is dependent on staff sighting the alert. There is no sound activated (or pager) call system to get assistance in an emergency (link 1.2.8). Staff interviewed confirm they are reliant on seeing that a call has been activated, and when attending to other residents a delay in response is incurred. Interviews with residents inform call bell response is sometimes delayed (also refer evidence 1.2.8). Ensure there is an effective method of summoning staff is in place, particularly in an emergency situation. 90 HDS(IPC)S.2008 Standard 3.1: Infection control management 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. PA Low HDS(IPC)S.2008 Criterion 3.1.3 The organisation has a clearly defined and documented infection control programme that is reviewed at least annually. PA Low The infection control programme has an issue date of 4/4/13 and review date of 4/4/15. The infection control programme requires annual review. Review the infection control programme annually. 180
Criterion 1.1.3.1 (HDS(C)S.2008:1.1.3.1) The service respects the physical, visual, auditory, and personal privacy of the consumer and their belongings at all times. 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 1.1.3.2 (HDS(C)S.2008:1.1.3.2) Consumers receive services that are responsive to the needs, values, and beliefs of the cultural, religious, social, and/or ethnic group with which each consumer identifies. 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 1.1.3.6 (HDS(C)S.2008:1.1.3.6) Services are provided in a manner that maximises each consumer's independence and reflects the wishes of the consumer. Attainment and Risk: FA Evidence: Finding: